Service Medical

SEAFARER'S APPLICATION FORM - Page * of * - PERSONAL DATA

PERSONAL INFORMATION

Family Name Shykalo First Name (s) Andrii

Birth Date 18-05-1993 Birth Place Kolodenka

Nationality Ukrainian Religion Catholic

Marital Status Single No. of

Children

Height (cm) 190 Weight (kg) 80

Parents Oleksandr, Nadia Mother maiden Popach

names(first) n.

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

or contact addresses if any)

Street & Nr. Starzynskiego 9 Email Address *.*******@**.**

Location Mobile Phone +487********

City Szczecin Residence

Phone

State, Country West Pomeranian, Fax

Poland

Postal (ZIP) 70 506 Nearest Berlin, Poznan

Code airport

NEXT OF KIN INFORMATION (person to contact in case of emergency &

insurance beneficiary)

Family Name Shykalo First Name(s) Oleksandr

Nationality Ukrainian Relationship Father

Street & Nr. Khmelnyckogo 39 Email Address

Location Mobile Phone +380*********

City Kvasyliv Residence

Phone

State, Country Rivne region, Ukraine Fax

Postal (ZIP) 35 350 P.O. Box (if

Code any)

REMARKS

Requested Rank Engine Cadet Availability 01.03.2015 -

Date 30.09.2015

Prefer. Vessel Minimum Salary

Type

English Language Advanced

Skills

Other Foreign Polish, Russia

Languages

Professional School / Maritime Academy in Szczecin

Academy - Name &

Period (From - To)

Period from 2012 to 2016

Foreign Crew

Experience

(specify

nationalities)

Other Skills

Further Remarks

I hereby affirm that all the information provided by me in this

application is true and correct to the best of my knowledge.

Date: Signature:

SEAFARER'S APPLICATION FORM - Page 2 of 3 - LIST OF DOCUMENTS

Please note that due to legal requirements boarding is only possible once

we are in possession of photo copies of all listed documents and

certificates - in urgent cases you may therefore have to send them by

courier, fax or email (.jpg format, scans max. 600 pixel wide or 900 pixel

high). Passport photos may arrive later (by mail).

Family Shykalo First Andrii Rank ENG. CAD. /

Name Name(s) WIPER

A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES

Document Name Document Number Country Issue Issue Exp.

(Desciption) Place Date Date

Passport ET 206856 Ukraine Rivne 15-07-2 15-07-2

011 021

Seaman's Book 0262956 Poland Szczeci 18-06-2 31-12-2

(national) n 013 018

Seaman's Book (flag

state)

Seaman's Book (flag

state)

Visa - United States

(type C1/D)

Visa - Others

(Work/Resid. Permits)

Medical Examination

Report

Drug & Alcohol Test

Vaccination against

Yellow Fever

Vaccination against

Cholera

Passport Photos

Document Name

(Desciption)

Basic Safety Training UMS-542*-****** Poland Szczeci 17-09-2 16-09-2

Certificate -8015/2012 n 012 017

Certificate of UMS-135*-****** Poland Szczeci 26-11-2 indefin

Proficiency for -25653/2013 n 013 itely

seafarers with

designated security

duties

Certificate of UMS-135*-****** Poland Szczeci 26-11-2 indefin

Proficiency in -25487/2013 n 013 itely

Security-awareness

HEALTH CERTIFICATE MLC 551/14 Poland Szczeci 10-10-2 10-10-2

n 014 016

Certificate of Traning UMS-130*-****** Poland Szczeci 28-01-2 indefin

in Liquified Gas Tanker -1410/2015 n 015 itely

Familiarization

Certificate of Traning UMS-133*-****** Poland Szczeci 28-01-2 indefin

in Oil and Chemical -1367/2015 n 015 itely

Tanker Familiarization

Wiper certificate UMS-131**-***** Poland Szczeci 12-02-2

4-426/2015 n 015

Date: Signature:

SEAFARER'S APPLICATION FORM - Page 3 of 3 - SEA SERVICE (LAST 5 YEARS)

Please indicate your sea service in the last 5 years as exact as possible

- required are the actual sign-on and sign-off dates according to the

service certificates resp. seaman's book

entries. To speed up processing kindly indicate phone and/or fax numbers of

your previous employers. Ship sizes are to be indicated in gross tons,

total engine output in kilo Watt

(1 kW = 1.34 bhp) to go along with STCW limitations. Please be prepared to

provide evidence for sea service that cannot be confirmed by reference

check.

The provided may be passed on to our clients and to flag state

administrations to allow for verification of rank experience. Please use

the European date format (DD.MM.YY).

Vessel's Name Flag

Contact this candidate