Medical Training

APPLICATION FORM

Persona data

SEAFARER'S APPLICATION FORM - Page 1 of 4 - PERSONAL DATA

Requested Rank: 3rd Officer / Availability Date 3of August 2013

2nd Officer

PERSONAL INFORMATION

Family Name Alakshin First Name(s) Anton

Birth Date 12.06.1985 Birth Place Perm reg., USSR

Nationality Russian Religion Christian

Marital Status Single Number of Children Nil

Eye's Color Blue/grey Hair's Color Brown

Height 180 cm Weight 75 kg

Safety Shoes 43 Boilersuit 52

Nearest Airport(s) Nizhniy Novgorod and Moscow

(International / Domestic))

Education: High school - faculty of Navigation

ADDRESS (include telephone country & area codes, advise also secondary or

contact addresses if any)

Nr., Street, 14, Khersonskaya str., 32 apt.

Apt.

City Nizhniy Novgorod Postal Code (Index) 603090

Country Russian Federation Home Phone +7-831-***-****

Mobile Phone +7-906-***-**** Contact Phone +7-906-***-****

Fax E-Mail Address **************@****.**

NEXT OF KIN INFORMATION (person-OLDER than 18 years-to contact in case of emergency

& insurance beneficiary)

Surname, Name Alakshin First Name(s) Aleksandr

Citizenship Russian Relationship Father

Nr., Street, 14, Khersonskaya str., 32 apt.

Apt.

City Nizhniy Novgorod Postal Code (Index) 603090

Country Russian Federation Home Phone +7-831-***-****

Mobile Phone +7-831-***-**** Contact Phone +7-831-***-****

Fax E-Mail Address **************@****.**

REMARKS

Availability Date June 2013

(Month, Year):

Foreign Crew Experience

(specify nationalities) Russia Ukraine Latvia Myanmar Filipino

Other Skills Poland

(specify details)

APPLICATION FORM

List Of documents

SEAFARER'S APPLICATION FORM - Page 2 of 4 - LIST OF DOCUMENTS

TRAVEL DOCUMENTS, SEAMAN'S BOOKS AND MEDICAL

CERTIFICATES

Document Name Document No. Country Issue Issue Exp. Date

(Description) Place Date

National Seaman's Passport RUS 0018317 Russia 14.04.201 14.04.201

(SID) 0 5

National Seaman's Book MK 0011779 Russia 16.04.201 17.01.201

0 5

Travel Passport 71 0111919 Russia 25.03.201 25.03.202

0 0

Seaman's Book - Luxemburg

Other s/book: Liberia 989955 Liberia USA 18.05.201 18.05.201

1 6

Cyprus CY129627 Cyprus Cyprus 11.09.200 10.09.201

8 8

Marshall Islands 0181909 Marshall USA 18.01.201 17.01.201

Isl. 0 5

Visa Schengen (specify

only if valid)

Medical Examination Report Russia 12.04.201 12.04.201

3 4

Drug & Alcohol Test

Vaccination against Yellow Russia 02.04.200 02.04.201

Fever 8 8

CERTIFICATES OF COMPETENCY (LICENSES) &

ENDORSEMENTS, FLAG STATE CERTIFICATES

License Name (Description)

National License 104******* Russia Kaliningr 06.03.201

(officers) Officer in ad 09.03.200 8

charge of a navigational 9

watch

National GMDSS General 0057120 Russia St. 27.05.201 06.03.201

Operator Certificate Petersbur 0 8

g

License: Luxemburg

Other Licenses:

Tanker Endorsement Oil 104******* Russia Kaliningr 09.03.200 15.11.201

ad 9 3

COURSE CERTIFICATES

Document Name Document Country Issue Issue Exp. Date

(Description) Number Place Date

Radar Observer & Plotting 0148471 Russia 05.04.201 05.04.201

3 8

A.R.P.A. 0148471 Russia 05.04.201 05.04.201

3 8

Basic Safety Training (4 0040756 Russia 06.03.201 06.03.201

components) 3 8

Proficiency in Survival 0041670 Russia 12.03.201 12.03.201

Craft and Rescue boats 3 8

Advanced Fire Fighting 0040999 Russia 15.03.201 15.03.201

3 8

Medical First Aid 158763 Russia 22.03.201 22.03.201

3 8

Medical Care 158763 Russia 22.03.201 22.03.201

3 8

HUET

HLO

DP Basic

DP Advance

ECDIS 0143147 Russia 26.04.201 26.04.201

3 8

HAZMAT 036381 Russia 11.11.200 11.11.201

8 3

APPLICATION FORM

ANY ADDITIONNAL INFORMATIONS OR JOB DESCRIPTIONS /EXPERIENCES YOU WANT TO

DETAIL IN PARTICULAR. WRITE HERE:

Detail the work you have done onboard previous vessels

VESSELS SECURITY TRAINING COURSE (SCM COMPANY) 743 05.12.2009

SECURITY-AWARENESS TRAINING OF SEAFARERS (A-VI/6, TABLE 0058712 26.03.2013 26.03.2018

A-VI/6-1)

OIL TANKER /FAMILIARIZATION/ PROGR. A-V/1, P.2-7 106601 15.11.2008 15.11.2013

HAZMAT (USA-TITLE 49) 025217 11.11.2008 11.11.2013

Safety Officer Training Course 0444 08.12.2009

Safe Navigation Training CSM Company 207 10.12.2009 10.12.2014

C-TRIM program Training CSM Company 526 02.04.2009 02.04.2014

Electr Ch display and inf. Syst. Tr. CSM Company 101 10.12.2009 10.12.2014

Port State & Vetting Inspections CSM Company 959 01.04.2009 01.04.2014

Bridge Team & resourse mangm tr CSM Company 171 11.12.2009 11.12.2014

ENGLISH

Marlins Test 90 % passed in 2009

1 REMARKS OF MASTERS FM LAST 3 VESSEL'S (APPRAISAL REPORT)

Good 3rd Officer / Showed himself as qualified and responsible Officer. He has good watch keeping experience, knowledge

and understanding duties of the Navigational Officer and in all respect is ready to occupy 2nd Officer position any

time. / Hardworking and responsible Officer with high sense responsibility and initiative.

APPLICATION FORM

All seagoing experience

SEAFARER'S APPLICATION FORM - Page 3 of 4 - SEA SERVICE ( Last 10

years)

Vessel's Name Gross Tonnage

(GRT)

Mystery K General cargo, big bag, barley, coal, cement, paint

Other vessels Container, IMDG, general

Contact this candidate