APPLICATION FORM
Surename | Gladkov | Mobile phone | +79788187870 | Position | A/B | |||||||||||||
Name | Sergey | Home number | Second choice |
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Father’s name | Andreevich | zasranecboy@mail.ru | Min wage |
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Date of birth | 03.07.1990 | Place of birth | Ukraine, Sevastopol | Height / Weight |
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Nationality | Russian | Home address | Ukraine c. Sevastopol st. Minska 13 | |||||||||||||||
Next of kin | Gladkova Irina | Next of kin Tel. | Relationship |
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Education | Name of Maritime College or Academy | From | Till | |||||||||||||||
medium | Crimea banch of Admiral Ushakov Maritime State Academy | 01.092007 | Present time | |||||||||||||||
Passports | Number | Place of issue | Date of Issue | Valid Until | ||||||||||||||
Seaman’s Book | 04285/2008/25 | Sevastopol | 05.11.2008 |
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Foreign Civil Passport | EK274698 | Sevastopol | 18.06.09 | 18.06.19 | ||||||||||||||
National Passport | AP414157 | Sevastopol | 03.07.07 |
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USA visa |
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License | Grade | Number | Place of issue | Date of Issue | Valid Until | |||||||||||||
Certificate of Competency | A/B | 00044/2013/11 | Kherson | 22.01.13 |
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Endorsement | A/B | 00044/2013/11 | Kherson | 22.01.13 |
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Certificate of Competency |
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Endorsement |
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STCW certificates | Number | Place of issue | Date of Issue | Valid Until | ||||||||||||||
Basic Safety Training and Instruction | Sevastopol | 20.12.12 | 31.12.16 | |||||||||||||||
Proficiency in Survival Craft | Sevastopol | 19.05.16 | 19.05.16 | |||||||||||||||
Designated Security Duties Of Shipboard Personnel | Sevastopol | 25.12.13 | 25.12.18 | |||||||||||||||
Carriage of Dangerous Substances |
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Medical First Aid |
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Oil Tankers Familiarization |
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Oil Tankers Specialized Training |
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Chemical Tankers Specialized Training |
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Liquefied Gas Tankers Specialized Training |
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Crude Oil Washing |
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Inert Gas System |
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Ro-Ro Passenger Ships |
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Passenger Ships other than Ro-Ro Passenger Ships | Sevastopol | 19.05.11 | 19.05.16 | |||||||||||||||
Foreign licenses, seamen’s books and endorsements | ||||||||||||||||||
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SEA SERVICE (Last 5 Employments) | ||||||||||||||||||
Rank | Vessel’s Name | Type | DWT | Flag | From | To | Owners / Country | Crew Agency | ||||||||||
A/B
| MR.GOKSU
| GENERAL CARGO | 3213.1 | COMOROS | 02/04/2010 | 01/03/2011 | Turkey | PANBAY SHIPPING AND TRADING CO. LTD | ||||||||||
A/B | Panamax Dawn | Bulk | CYPRUS | 05/05/11 | 10/11/11 | Cyprus | CYPRUS MARITIME CO LTD | |||||||||||
A/B | Frio Shinano | Reefer | Panama | 14/01/14 | 23/05/14 |
| UKRAINIAN-GREEK CREWING COMPANY | |||||||||||
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Відповідно до Закону Украйни, Про захист персональних даних N2297-VI від 01.06.2010р., надаю згоду на обробку моїх персональних даних, вказаних в анкеті, з метою можливого працевлаштування на суднах іноземних судовласників. З вимогами Закону Украйни, Про захист персональних даних”, правами
та обов’язками сторін ознайомлений.
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