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Personal application form

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POSITION
Position applied for: Deck cadet Date 12.03.2013
Nomination for m/v General cargo Availability  
Applicant was interviewed by Bogdanov Andrey Desired min salary 650$
English level пптттт()()()()(satisfactorygood, bad) Middle    

 

PERSONAL INFORMATION
Ф.И.О. на русском языке Богданов Анлрей Анлреевич
Family name Bogdanov Permanent address Kherson, Stepanovka, st. Zelenaya 67
Name Andrey Post code  
Date of birth 09.11.1993 Phone home  
Place of birth Crimea Phone mobile +380999017994
Nationality Ukrainian E-mail address batanik_baron@mail.ru
Tax ID number   Overall size: S / M / L / XL / XXL Shoes size:  
Height / Weight 177Framed/62kg Hair/ Eyes: Brown/Brown
  EDUCATION BACKGROUND From To Diploma No. Highest qualification  
  Kherson Maritime College of Fish industry          
             
  FAMILY DETAILS  
  Next of kin(Last and first name) Bogdanova Natalya Oleksandrovna   Next of kin relation mother  
  Next of kin email nata_bogd@mail.ru  
  Next of kin address + post code Kherson, Stepanovka, Zelenaya 67 Next of kin contact phone 1st Next of kin contact phone 2nd +380999016929  
     
           
  Names of children Sex Date of birth  
         
           
         
  Wife's full name (if married)   Wife's date of birth    
  IDENTITY DOCUMENTS Country Number Issued Place Expiry  
  Civil passport Ukraine MP315126 09.03.2010 Kherson    
  International Passport Ukraine EP595194 12.12.2012 Kherson 12.12.2022  
  Seaman’s Book Number of free pages:__ Ukraine AB500758 28.05.2012 Kherson 25.05.2022  
  Dutch          
  Seaman’s Book Number of free pages:30__ Ukraine 00241/2011/26 02.02.2011      
  Do you hold a US VISA C1/D? no        
  Do you hold a Schengen Visa? no        
                                                     

 

 

CERTIFICATE OF COMPETENCY Rank Number Place Issued Expiry
National License          
National STCW Endorsement          
National GMDSS certificate          
GMDSS STCW Endorsement          
Belize License          
Malta License          
Liberia License          
Cyprus License          
Dutch License          
Other License          
  STCW CERTIFICATES Number Place Issued Expiry  
  Basic safety training (A-VI/1 STCW'95) 6954/mps 22.10.2010 Kherson 22.10.2015  
  Proficiency in survival craft (A-VI/2 STCW'95) 16627/mps 22.10.2010 Kherson 22.10.2015  
  Advanced fire fighting (A-VI/3 STCW '95) 04716/mps 22.10.2010 Kherson 22.10.2015  
  Medical first aid (A-VI/4-1 STCW '95) 2400/mps 22.10.2010 Kherson 22.10.2015  
  Medical care (A-VI/4 STCW '95)          
  Radar observer (ROPS)          
  ARPA certificate          
  Ship security officer (ISPS code)          
  Hazardous cargoes (B-V/4, B-V/5 STCW)          
  RO-RO other than passenger ships          
  Certificate re-validation course (II/2 STCW)          
  Certificate of ISM code (A-1/14)          
  Ship handling and maneuvering simulator          
  Compressed Air Breathing Apparatus          
  ECDIS (DECK OFF)          
  Bridge or Engine Resource Management          
  Bridge Team Management          
  Engine simulator          
  Maintenance of Electrical and Electronic Engin.          
  Ship's Welder          
  Ship's Turner          
  Ship's Cook          
  DP Certificate (indicate type)          
PASSENGER SPECIFIC Number Place Issued Expiry  
Crowd management (V/3, STCW)          
Crisis man and human behavior (Ro, RoPax)          
Pax, Saf, Cargo & Hull integrity          
Pax Safety          
RO-RO passenger ships (A-V/2 STCW)          
Familiarisation training          
                               

 

TANKER SPECIFIC Number Place Issued Expiry
Tanker familiarization (V/1, A-V/1 STCW)        
Familiarization - Oil tanker (V/1 1.1-2, A-V/1 prg.1-7)        
Oil Tanker Advanced Training (V/1.2, A-V/1 STCW)        
Familiarization - Chemical tanker(V/1 1.1-2, A-V/1 prg.1-7)        
Chem. Tanker Advanced Training(V/1.2, A-V/1 STCW)        
Familiarization - LPG/LNG (V/1.2, A-V/1 STCW)        
LPG/LNG Advanced Training(Res.11,12, V/1.2, A-V/1 STCW)        
Crude oil washing (A.446/XI STCW, MARPOL)        
Inert gas        
Vapor Recovery Systems        

 

TRAINING COURSES(any non STCW trainings, courses and etc.) Location Duration Date
       
       

 

MEDICAL HISTORY YES NO  
Medical pre-employment examination. Issue date:04.07.2012 Valid till:04.07.2013  
Drug and alcohol test. Issue date:04.07.2012 Valid till:04.07.2013  
Yellow fever vaccination.     Valid till Issue date: Valid till:  
Other vaccinations. Issue date: Valid date: Valid till  
(if the answer is YES to any of the above, please give full details and attach a separate signed and dated page if necessary)  
RECORDS OF PREVIOUS SERVICE(please give a full record starting from last vessel on which you served)
Name of vessel   Flag Year built Vessel type DWT Engine type KWT Managers Crewing agent Rank Signed on     Signed off     Months / Days
BT-426 Ukraine   Tug 8.9 Diesel   World Line LTD World Line LTD Deck Cadet 06.06.2011 01.09.2011 3 months
Okski-56 Ukraine   Dry-Cargo 13.1 Diesel   World Line LTD World Line LTD Deck Cadet 26.05.2012 26.02.2013 9 months
                         
                         
                         
                                   

 

REFERENCES:please, fill up on below rows the full address and phone number of your previous company
  Name of company Name of company: World Line LTD Address Kherson, Krasnoflotskaya 35
Name of person to contact   Telephone number  
FOR OFFICE USE ONLY: references are POSITIVE NEGATIVE REQUEST REJECTED REFEREE NOT REACHED
Remarks:
  Name of company World Line LTD Address Kherson, Krasnoflotskaya 35
Name of person to contact   Telephone number  
FOR OFFICE USE ONLY: references are POSITIVE NEGATIVE REQUEST REJECTED REFEREE NOT REACHED     Name of company Name of company: Address Name of person to contact Telephone number
Remarks:

 

Marlin's English test passed: Date: Professional test: Date

 

I hereby declare that above, including Medical History, is true. I accept any “EMES CREWING” investigation in my respect with any party concerned. Further, I confirm that I give the rights to “EMES CREWING” to share my personal data with any parties worldwide for service purposes or as required applicable legislation. I understand that my working contract will be canceled without notifying if any submitted information and document are voted as false.

 

Applicant signature_________________________ Place: ______________ Date_____________________


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