Safety Officer Medical

PERSONAL DATA / APPLICATION FORM

Family Name: Griaznov

Name: Yaroslav

Father's name: Olegovich

Date of birth: 6.11.1993

Place of birth: Kherson. Ukraine

Nationality: Ukrainian

Marital status: Single

Address: apt. 353, 22, 200 Years of Kherson avenue, Kherson, Ukraine

Nearest Airport: Odessa

Skype: yarrik_1993_6

E-mail: *******@*****.***

Mobile phone: +380*********

Next of kin and relationship: Tatyana / Mother

Children (name & DOB):

Next of kin’s address: apt. 353, 22, 200 Years of Kherson avenue, Kherson, Ukraine

Next of kin tel: +380*********

Inter. P’port No: EX 093076

Issued: 29/05/2013

Valid: 29/05/2023

Place of issue: Kherson, Ukraine

Seaman's book No: AB 515150

Issued: 06/08/2013

Valid: 06/08/2018

Place of issue: Kherson, Ukraine

Civil P’port No: MP 315240

Date of issue: 16/03/2010

Place of issue: Kherson, Ukraine

USA visa No:

Issued:

Valid:

Place of issue:

Seaman`s seagoing service record book : 01224/2012/26

Issued: 25.04.2012

Valid: unlimited

Place of issue: Kherson, Ukraine

Computer: Excellent

Personal No: 342-***-****

Web: vk.com/real_free_life

English: Good

SEA GOING EXPERIENCE FOR THE LAST 7 YEARS

(MOST RECENT VESSEL LAST)

Name of vessel

Year of built

Company Owner /

Ship Manager

Flag

Type of vessel

DWT /

TEU

ME type /

Model

BHP

Rank

From

DD/MM/YYYY

To

DD/MM/YYYY

KILIYA

1967

Kherson Seaport (KCSP)

Ukraine

Dry Cargo

2500

6NVD48

1300

Motorman

26/04/2012

30/12/2012

VOLODYMYR SHARKOV

1984

JSSC URRICHFLOT

Ukraine

Dry Cargo

5000

6NVD48

1324

3rd Engineer

14/05/2014

16/06/2014

Name of Maritime Institution attended

Address of institution

From

To

Degree of Diploma

Kherson Maritime College Of Fishing Industry of Kerch University

Lenin street 55, Kherson, Ukraine (73025 )

01/09/2010

03/07/2013

Junior specialist

STCW Certificates

Number

Issued

Valid

Place of issue

STCW Certificates

Number

Issued

Valid

Place of issue

Certificate of competency

01536/2013/11

21.08.2013

Unlimited

Kherson, Ukraine

Basic training for liquefied gas tanker cargo operations

1761/MPS

26/06/2015

26/06/2020

Kherson, Ukraine

Endorsement

01536/2013/11

21.08.2013

31.12.2016

Kherson, Ukraine

Basic training for oil and chemical tanker cargo operations

3710/MPS

26/06/2015

26/06/2020

Kherson, Ukraine

Personal safety

2240/MPS

06/04/2012

31/12/2016

Kherson, Ukraine

Security – related training and instruction for all seafarers

8664/MPS

11/04/2014

11.04.2019

Kherson, Ukraine

Advanced fire fighting

04123/MPS

19/07/2013

19/07/2018

Kherson, Ukraine

Designated security duties of all shipboard personnel

10153/MPS

11/04/2014

11/04/2019

Kherson, Ukraine

Prof. in survival craft

2278/MPS

06/04/2012

06/04/2017

Kherson, Ukraine

BTM course

Medical first aid

2713/MPS

19/07/2013

19/07/2018

Kherson, Ukraine

ECDIS course

Medical care

Security officer (ISPS)

Hazardous cargoes

8695/MPS

19/07/2013

19/07/2018

Kherson, Ukraine

Safety officer (ISM)

Passenger vessel training & Ro – Ro

2895/MPS

26/07/2013

26/07/2018

Kherson, Ukraine

Medical examination

Issued: 28.07.2015

Valid:28.07.2016

Weight, kg: 70

Height, cm: 179

Drug & alcohol test

Issued: 28.07.2015

Valid: 28.07.2016

Eyes: Grey

Hair: LIGHT

Yellow fever

Issued: 29.07.2015

Valid: 29.07.2025

Overall size: 48

Safety shoes: 42

Please complete addresses of your previous employers for references

Company

KCSP

Tel +380 (552) 223248

Company

JSSC UKRRICFLOT

Tel: +38 (0552) 44 03 51

Address

Ushakov Avenue 4, Kherson, 73000, Ukraine.

Address

6. Odessa Sq., Kherson, Ukraine

Signature: Date: 14.08.2015

Contact this candidate