Position applied for: motorman

APPLICATION FORM

POSITION APPLIED FOR: Motorman

Personal data 28.11.2014

Family Name: Valevych	Name: Andrii	Father's name: Nikolay
Date of birth: 06.11.1982	Place of birth: Kherson	Nationality: Ukraine
Marital status: single	Children: none
Address : Ukraine, Kherson, Kamyshany, Mekhanyzatorov 8.	Tel	Mobile; [phone]
Next of kin and relationship: Nikolay .-father, Elena .-mather
Next of kin’s address :	Tel:
Inter. P’port No:EK491090	Issued: sep 09	Valid: sep 19	Place of issue: Kherson
Seaman's book No: AB542200	Issued :okt 14	Valid: sep 19	Place of issue: Kherson
Civil P’port No: MO 668972	Place of issue: mar 99	Date of issue:
USA visa No:	Issued:	Valid:	Place of issue:

Medical information

Medical examination	Issued:sep 14	Valid:sep 15	Weight, kg :70	Height, cm: 176
Drug & alcohol test	Issued: jan 15	Valid: jan 16	Eyes:green	Hair: brown
Yellow fever	Issued:	Valid:	Overall size:	Safety shoes: 42

Name of marine school attended	Address of school	From	To	Degree of diploma
Training centre “AVANT”	Illichivsk	01.11.13	15.05.14

National License

Certificate of competency hold	Number	Issued	Valid	Place of issue
Диплом	12308/2014/11	06.11.2014		Kherson
Endorsement

IMO	STCW Certificates	Number	Issued	Valid	Place of issue
	GMDSS Endorsement
	Carriage of dangerous and hazardous substances
1.08	ARPA (A-I/12, A-II/1, A-II/2, B-I/12)
	Personal safety (A-VI/1) (IMO 1.13, 1.19, 1.20, 1.21)	No. 20 570	08.08.2014	08.08.2019	Illichivsk
2.03	Advanced fire fighting (A-VI/3)
1.23	Prof. in survival craft (A-VI/2 p.1-4)	No. 16 244	08.08.2014	08.08.2019	Illichivsk
1.14	Medical first aid (A-VI/4-1)
1.15	Medical care (A-VI/4-2)
	Hazardous cargoes (B-V/4, B-V/5)
	Security avareness(A-VI/6)	No.20 387	08.08.2014	08.08.2019	Illichivsk
	Crowd management (A-V/3)
	Bridge Team Management
	Training for person. serving onpassenger ships other than RO-RO pas.ships
	Designated security duties of shipboard personnel	№ 29451/MPS	26.12.2014	26.12.2019	Kherson
	Ship security officer
	Ship handling arrangements
	Свид-ство о повышении квалификации

Dangerous cargoes certificates

1.01	Oil tank. familiarization (A-V/1)
1.02	Oil tank.Specialized training (A-V/1,p.9-14)
1.03	Chem. tank. familiarization (V/1)				.
1.04	Chem. tank. advanced (A-V/1,p.16-21)
1.05	LPG familiarization (V/1)
1.06	LPG advanced (A-V/1,p.23-34)

PREVIOUS SEA SERVICES (last 5 years)

Name of vessel	Year of built	Company	Flag	Type of vessel	DWT	Type of main engine	BHP	Rank	From Day,mont,year	To Day,month,year
m/v “Diorit”		“Black Sea State”	ukr	Reserch/ Survey		SKL 48V8		cadet	11.03.2014	13.05.2014

Another States Seamen’s Books	Rank	Document No	Issued	Valid		Another States Certificates of competency	Rank	Document No	Issued	Valid
Liberia						Liberia
Panama						Panama

Please complete addresses of your previous employers for references

Company	«»	Tel:	Company		Tel:
Address		Address

Signature____________________ Date ______________­__ I understand, that my working contract will be canceled without notifying if any of submitted information and documents are voted as false.

FOR OFFICIAL USE ONLY English abilities: Good: Average: Poor:

(To be filled by Company’s authorised personnel) 10 9 8 7 6 5 4 3 2 1

Good spoken and written Understand basic instructions Do not understand basic instructions

Дата добавления: 2015-08-27