APPLICATION FORM
Position Applied for
Engine cadet
Alternative
Wiper
Surname
Manoli
First name
Ievgen
Patronymic
Ivanovich
Date & place of birth
Nationality
UKRAINIAN
Marital status
Single
Children under 18 years -
Height 177
Weight 75
Overall size M-L
Shoes size 42-43
Address
Street
Solomyanska street, 20
City/Country
Kyiv, Ukraine
Airport(s)
Borispol
Tel:
c
Mobile
E-mail:
**********@****.**
Next of Kin
Name / Relationship
Irene Manoli, mother
Date of birth
27 April 1973
Street*
Pionerskaya, 26
City/Country*
Izmail, Urkaine
Tel*
Mobile
E-mail:
*****-********-**@****.**
* if same as above – please insert “As above”
Name of School / Academy attended
Address
Dates Attended
Type of Degree or Diploma
From
To
Received upon Graduation
Kyiv state maritime academy
Kyiv, Frunze, 9
01.09.2013
31.05.2017
Engineer in degree of Bachelor, third course
SEA SERVICE (from latest to previous)
NAME OF VESSEL
Position
Vessel’s type
Engine
Flag
Owner
Period of service
DWT
BHP
Year of built
Crew Agent
Alma-Ata
Engine cadet
Tug Boat
3D6
Ukraine
Izmail seaport
08.06.2015
75
2x750
1974
08.08.2015
Portoviy-5
Engine cadet
Tug Boat
8ЧСП 18/22
Ukraine
Izmail seaport
12.05.2014
45
2x215
1985
12.08.2014
DOCUMENTS / VISAS
Type of documents
Place of issue
Serial Number
Issue Date
Expiration date
Seaman’s book
Izmail
AB 545763
23.03.2015
23.03.2020
Trav. Passport
Kyiv
FB 414466
29.04.2015
29.04.2025
USA Visa
Certificate. of Competency
Second class motorman
Izmail
11682/2015/01
08.07.2015
Endorsement
Izmail
GMDSS:
GMDSS Endorsement
FoC section
Flag of Convenience Documents & Certificates :to be fill in only for
Marshall Isl. / Liberia / Cayman Isl. / St. Vincent / Bahamas / Bermuda
SIRB /Seaman’s book
Certificate of competence
SQ
GMDSS
STCW 78/95 CERTIFICATES & OTHER CERTIFICATES
CERTIFICATE
Place of issue
Serial Number
Issued on
Valid till
Personal survival techniques, (VI/1)
Izmail
11430U
06.05.2014
06.05.2019
Proficiency in survival craft & rescue boats other then fast rescue boats (VI/2)
Izmail
24389U
22.01.2015
22.01.2020
Advanced fire fighting (VI/3)
Medical First Aid (VI/4-1)
Medical Care (VI/4-2)
Carrying Dangerous and HazardousCargoes
Tanker familiarization (A-V/1), p 1-7
Oil tanker specialized (A-V/1), p 8-14
Chemical tanker specialized (A-V/1) p15-21
Gas tanker specialized (A-V/1) p22-32
Ship Security Officer (ISPS Code)
Safety Management System (ISM Code)
ECDIS – Electronic Chart Display and Information System
Bridge Team Management
MEDICAL EXAMINATION
DRUG and ALCOHOL TEST:
VACCINATION
Clinic:
Республіканська клінічна лікарня Міністерства охорони здоров’я України
Республіканська клінічна лікарня Міністерства охорони здоров’я України
Yellow Fever
Date of examination
5.03.2015
5.03.2015
Date of vaccination
-