.
| Position applied for: | / 2 | Available from: | ||||||||||
| : | / | : | ||||||||||
| Surname: | First name: | Second name: | ||||||||||
| : | : | : | ||||||||||
| Date / Place of birth:03.04.1996 . - | Nationality: | |||||||||||
| / : | / | : | ||||||||||
| Name of educational institution | Year of entry | Year of graduation | Competency Grade |
| , | |||
| 08 2015 | 31 2015 | 2 | |
| 01 2013 | 20 2014 |
| CERTIFICATES | QUALIFICATION | NUMBER | Date of issue | Place of issue |
| Certificate of Competency / | 13806/2015/01 | 02.10.2015 | ||
| Endorsement / . | 003419 | 02 |
| DOCUMENTS | NUMBER | DATE OF ISSUE | PLACE OF ISSUE | DATE OF EXPIRY | |
| Seamans book / | 555606 | 19 | |||
| International passport / | FB785271 | 04 2015 | 04 2025 | ||
| Ukrainian passport / | 788761 | 25 2012 | |||
| Health List / | 924702 | 01.06.2016 | |||
| Drug & Alco Test / / | 601088 | 07 2016 | 07 2017 | ||
| Yellow Fever/ | ------- | ----- | ----- | ---------- | |
| Other countries | Marshall Islands | ||||
| Liberia | |||||
| Panama | |||||
| Others: | |||||
| Tax Number / | 27.06.2013 | ||||
| USA VISA ( ) | ------- |
SEA SERVICE FOR LAST 5 YEARS / 5
| Name of vessel | Flag | Type | GT/DW | Engine | KW | Agency | Rank | From | Till | |
| / | / | . | ||||||||
| \ | 01.02.15 | 05.06.15 | ||||||||
| References: Yes No : | Appraisals: Yes No : | Promotion to: : | ||||||||
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| Home address: - . 144 | |||||
| : | |||||
| e-mail: | home tel:(04841)76381 | mob.tel:+380685591168 |
CERTIFICATES AND QUALIFICATIONS
| CERTIFICATE | NUMBER | Date of issue | Authority | Place of issue |
| Sefat familiarization basic training andinstruktion for all seafarers | 14/09/2015 | 14.09.2020 | ||
| Security-Related training and instruction for all seafarers | 14/09/2015 | 14/09/2020 | ||
| Proficiency in survival craft and rescue boats other than fast rescue boats | 02/06/2016 | 02/06/2021 |
| Height (cm): | Weight (kg): | Color: eyes | hair:_______ | Size: overall | shoe | ||||||||||||||
| (): | (): | : | |||||||||||||||||
| Marital status: | Children: name | date of birth: | 11.07 2015 | ||||||||||||||||
| : | : | : | |||||||||||||||||
| Name next of Kin, relation: | Address next of Kin: | - . 144 | |||||||||||||||||
| , : | : | ||||||||||||||||||
| S/N | Wife/Husband: | address: | - . 144 | ||||||||||||||||
| : | /: | : | |||||||||||||||||
| Father: | address: | - . 144 | |||||||||||||||||
| : | : | ||||||||||||||||||
| Mother: | address: | - . 144 | |||||||||||||||||
| : | : | ||||||||||||||||||
Signature of Seamen: _____________ Date:___25.07.2016___________ CREW OFFICER: EPI VPS AVM IPD _________________
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:
| - , , 2297-VI 01.06.2010 . _________ ____________________________________( ) |
