S E A M A N ' s A P P L I C A T I O N F O R M

S E A M A N ' s A P P L I C A T I O N F O R M

A. SEAMAN'S PERSONAL DETAILS
POSITION TO APPLY FOR	3RD OFFICER	CERTIFIED FOR
NAME / SURNAME	IGOR KICHUK
FATHER'S NAME	VLADYMIR	MOTHER'S NAME	NATALIA
D.O.B./P.O.B.	02.07.1982 ODESSA	NATIONALITY	UKRANIAN
Height (in cm):	Weight (Kg):68	Shoes size:41-42	Parka size:48-50
ADDRESS	UKRAINE, ODESSA, BOGATSKOGO STR., 55, APP. 28
MOBILE No.: PHONE No.:	([phone] ([phone]	SKYPE ADDRESS:	igor.kichuk
MARITAL STATUS	MARRIED YES X NO q	CHILDREN YES X NO q	HOW MANY UNDER 18 YRS OLD..2..
NEXT OF KIN	KICHUK MARINA	RELATION	WIFE
SEAMAN'S PASSP NO.	AB 536356	ISS / VALID DATE	16.09.14 / 16.09.19
CIVIL PASSP NO.	KK 106310	ISS / VALID DATE	13.10.1998
AUSTRALIAN MCV No.		ISS / VALID DATE
GRADUATED FROM	ODESSA NATIONAL MARITIME ACADEMY 1999 - 2005
ENGLISH ABILITY	FLUENT q	VERY GOOD q	GOOD X	FAIR q

B. NATIONAL CERTIFICATION
CERTIFICATE	NUMBER	ISSUING - VALIDATION DATE	ISSUING PLACE
CERTIFICATE OF COMPETENCY	12252/2014/08	09.09.2014	ODESSA
ENDORSEMENT OF CERTIFICATE	12252/2014/08	09.09.2014 - 04.09.2019	ODESSA
GMDSS (DECK OFF.)	11886/2014/08	20.08.2014	ODESSA
ENDORSEMENT OF GMDSS	11886/2014/08	20.08.2014 - 18.08.2019	ODESSA
SHIP SECURITY OFFICER		06.08.2014 - 06.08.2019	ODESSA
DESIGNATED SECURITY DUTIES	0294/2014	06.08.2014 - 06.08.2019	ODESSA
BASIC SAFETY		06.08.2014 - 06.08.2019	ODESSA
PROFICIENCY IN SURV CRAFT		06.08.2014 - 06.08.2019	ODESSA
MEDICAL FIRST AID		06.08.2014 - 06.08.2019	ODESSA
ADVANCED MEDICAL CARE
ADVANCED FIRE FIGHTING		06.08.2014 - 06.08.2019	ODESSA
RADAR (DECK OFF.)		08.08.2014 - 08.08.2019	ODESSA
ARPA (DECK OFF.)		08.08.2014 - 08.08.2019	ODESSA
ECDIS		06.08.2014 - 06.08.2019
BRIDGE TEAM MANAGEMENT		06.08.2014 - 06.08.2019
DYNAMIC POSITIONING OPERATOR	11/424/2014	14.11.2014	ODESSA
C.O.W. / IGS
LAST MEDICAL		05.08.2014 - 05.08.2015	ODESSA
VACCINATIONS	YELLOW FEVER: DOI....22.09.2014.... DOE.... 22. 09. 2024 …… CHOLERA: DOI …………………… DOE ……………………

C. FLAG CERTIFICATION
FLAG	TYPE / No. (S.BOOK/ENDORS/STICKER)	RANK	ISSUED	VALID	Based on NATIONAL ENDORSEMENT NUMBER
	/

D. PREVIOUS SEA SERVICE
VESSEL	FLAG	TYPE/DWT	ENG/HP	RANK	S/ON	S/OFF	COMPANY
BLUE PRINCESS	LIBERIA	B/C / 37,049	SULZER/9,500	3RD OFF	10.10.06	10.05.07	V'SHIPS
BLUE PRINCESS	LIBERIA	TN-C / 37,049	SULZER/9,500	3RD OFF	26.08.05	15.06.06	V'SHIPS
EUROCARRIER	MALTA	R/R / 7,662	SEMT/8,190	3RD OFF	15.12.03	15.06.04	SAFINA
GEROI PLEVNY	UKRAINE	VFERRY/19,019	B&W / 17,600	CDT-DECK	13.06.01	29.09.01	UKRFERRY
GEROI SHIPKI	UKRAINE	VFERRY/20,000	B&W / 17,600	CDT-DECK	19.05.00	24.08.00	UKRFERRY

Version: 1/13 Seaman’s Signature……………………………

Дата добавления: 2015-11-04