Application Form

CR**[pic]

Agent Rank Applied Vessel Date Applied

Deck Cadet

Personal Details

First Yurii Nationalit Ukrainian Height 175 Nearest Odessa

Name y airport

Surname Ratushnyi No. of 0 Weight 60 Languages Russian

children

Date of 09.04.1996 Next of Father Color of Brown English Good

Birth kin eyes

Place of Ukraine Name of of Kin Color of Dark German No

Birth Next hair Blonde

Home Yurii Overall 48 Spain No

Address/Telephones size

303 Apt., 103 Illich Address of Next of Shoe size 41 Bank Details

str., Kherson, Kin: 303 Apt., 103

Ukraine 73020 Illich str., Kherson,

Ukraine

Remarks

Telephone +380669359 Telephone +380952085

No. 764 No. 407

E-mail:

acon15@r.postjobfree.com

Travel Documents

Passport MP379820 Seaman's AB532970 Travel ES361565 US visa

No. passport No. doc. number

No.

Place of Kherson Place of issue Kherson Place Kherson Place of

issue of issue

issue

Date of 24.05.2012 Date of issue 14.07.20 Date of 13.10.2014 Date of

issue 14 issue issue

Date of Date of expire 20.05.20 Date of 13.10.2024 Date of

expire 19 expire expire

Place of study Flag State Seaman's Books

Place Name From To Nationalit Number Date of Expire

y Issue

Of Antigua

instituti

on

Kherson KSMA 2013 2017 Cyprus

Liberia

Panama

Germany

Norway

Certificates

Type Issue

Place of Date of Issue Date of Expire Yellow Fever Rams Moskow 27.02.2015

Issue S.N518

Cholera

Sea Service

Name of Vessel Type of Vessel Flag

Signature: Documents held by the

seafarer!

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