APPLICATION FORM
PERSONAL DESCRIPTION:
Rank : Deck cadet/OS
Surname: Tretyakov
Name: Rostyslav
Middle Name: Victorovich
Date of Birth: 26.07.1999
Place of Birth:
Ukraine, Kherson
Citizenship: UA
Marital Status: Single
Address: Kramskogo lane, 3
Phone: +380*********
Next of Kin: Marina Faraponova
Address: Kramskogo lane, 3
Phone: +380*********
ENGLISH: high
Total Experience: -
e-mail: ******.*********@*****.***
GENERAL DETAILS:
Documents
Issued
Valid Until
Place
National Passport
MP471248
01.09.2015
-
Kherson
Size: L
Traveling Passport
FE095545
26.01.2016
26.01.2026
Kherson
High: 183
Seaman’s Book
AB581414
04.07.2016
03.06.2021
Kherson
Shoes: 42
Medic. cert.
-
-
-
Kherson
Weight: 70
PRE-SEA EDUCATION:
Name of Marine School
Department
Graduated on
MC KSMA
Navigation
study at 4th course
CERTIFICATES OF COMPETENCY:
Grade
Place of issue
Date of issue/validity
National
-
-
-
-
Endorsement
National
Endorsement
GMDSS
Endorsement
FLAG STATE PASSPORTS, LICENSES, VISAS AND OTHER DOCUMENTS
Document name/Details
Number
Issued
Valid
Certificate of proficiency
10974/2017/11
05.07.2017
-
SEA SERVICE (DURING LAST FIVE YEARS)
Rank
Vessel’s Name
Vessel’s type/DWT
ME type/
HP
Company
Flag
From
month/year
To
month/year
1.
Deck cadet
“Dunai”
Sea tug/128 g.t.
600 kWt
Ukrainian sea port authority
UA
07.06.2016
31.08.2016
2.
3.
4.
5.
6.
7.
8.
STCW – 78/95 and other certificates.
Document
Number
Issued
Valid
Issued Place
Basic Safety Training
27747
10.10.2015
10.10.2020
KMSTC under KSMA
Proficiency in Survival Craft
11632
30.04.2016
30.04.2021
KMSTC under KSMA
Proficiency in Fast Rescue Boats
Advanced Fire Fighting
7373
06.03.2017
06.03.2022
KMSTC under KSMA
Medical Care
8932
06.03.2017
06.03.2022
KMSTC under KSMA
GMDSS Certificate
GMDSS Endorsement
Radar Observation & Plotting
Automatic Radar Plotting Aids
ECDIS
Dangerous & Hazardous Cargoes
Hazardous materials
Ships Safety Officer
Ships Security Officer
Isolating Breathing Apparatus
RO-RO Passenger Ship
“ADMIRAL”
RO-RO Ship
Oil Tanker Familiarization
Oil Tanker Specialized Training
Oil T. cargo & ballast handling hhhahandling
Oil T. Op.&maint. of inert gas
Liq. Gas Tankers Spec. Training
Liq. Gas Op.&maint. of inert gas syst.
Liq.Gas T.cargo & ballast handling
Chem. Tankers Spec. Training
Chem. T. Op.&maint. of inert gas
Chem. T. cargo & ballast handling
Crude oil washing
Bridge Team & Res-s Management
Ship Handling Arrangement (M.L.)
ISM code
Designated Security Duties
7599
28.03.2017
28.03.2022
KMSTC under KSMA
Security
11403
28.03.2017
28.03.2022
KMSTC under KSMA
I, undersigned, confirm that all details provided on the form are correct.
Signature: Date: 20.07.17
Згоден на обробку моїх персональних даних згідно з законодавством.
Підпис: