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

For m/v:

CREWING MARINE AGENCY “A.T.T.-Bermudas”

Readiness

04.07.2017

JN:

SV

A.SEAMAN'S PERSONAL DETAILS

POSITION TO APPLY FOR

Motorman 2nd class/Eng. cadet

CERTIFIED FOR

NAME / SURNAME

Oleksandr Makhno

FATHER'S NAME

Oleksandrovich

MOTHER'S NAME

Polishchuk

D.O.B./P.O.B.

25.02.1998/ Ukraine, Mariupol

NATIONALITY

Ukraine

ADDRESS

Ukraine, Mariupol, Poinerskaya 83

PHONE NO.:

MARITAL STATUS

MARRIED YES

NO

CHILDREN YES

NO

HOW MANY

UNDER 18 YRS

OLD ?

NEXT OF KIN

Svetlana Polyshchuk

RELATION

Mother

SEAMAN'S PASSP NO.

AB574690

ISS / VALID DATE

25.02.2016/25.02.2021

CIVIL PASSP NO.

ВТ085271

ISS / VALID DATE

11.04.2014

GRADUATED FROM

Kyiv State Academy of Water Transport after Hetman Petro Konashevich Sagaydachnogo

ENGLISH ABILITY

FLUENT

VERY GOOD

GOOD

FAIR

B. NATIONAL CERTIFICATION

CERTIFICATE

NUMBER

ISSUING - VALIDATION DATE

ISSUING PLACE

CERTIFICATE OF COMPETENCY

01435/2017/06

20.06.2017

Mariupol

ENDORSEMENT OF CERTIFICATE

GMDSS (DECK OFF.)

ENDORSEMENT OF GMDSS

SHIP SECURITY OFFICER

9200

25.07.2017/25.07.2022

Marine consulting/service. Mariupol

BASIC SAFETY

455

21.03.2016/21.03.2021

Kyiv centre of training of seafarers

PROFICIENCY IN SURV CRAFT

4391

24.03.2016/24.03.2021

Kyiv centre of training of seafarers

MEDICAL FIRST AID

ADVANCED MEDICAL CARE

ADVANCED FIRE FIGHTING

6027

28.03.2016/28.03.2021

Kyiv centre of training of seafarers

HAZARDOUS CARGO

RADAR (DECK OFF.)

ARPA (DECK OFF.)

C.O.W. / IGS

OIL TANKER SAFETY

CHEMICAL TANKER SAFETY

LPG SAFETY

LAST MEDICAL

VACCINATIONS

YELLOW FEVER:

VISA USA :

DOI

DOI

DOE

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

OWNERS

Icebreaker "Captain Belousov"

Ukraine

Icebreaker/ 1446 t

Caterpillar/ 8832 kWt

Motorman- trainee

21.06.2016

04.08.2016

Mariupol commercial sea port

Version: 7/03 Seaman’s Signature

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