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: ac3dwl@r.postjobfree.com

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:

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