APPLICATION FORM

POSITION APPLIED READY FROM **/April/2016

PERSONAL DATA

FIRST NAME

Serhii

SURNAME

Homeniuk DATE OF

BIRTH

**/ **** /****

NATIONALITY

ukrainian

CITIZENSHIP

Ukrainian

PLACE OF

BIRTH

Ukraine

MARITIAL

STATUS

Single CHILDREN

UNDER 18

No FATHER’S

NAME

Vitalii

FULL

ADDRESS

Poland,Gdynia,

Wachowiaka 9

m.38

TELEPHONE

NO

+478*******

E-MAIL

homeniukserhii

@gmail.com

NEXT OF KIN (NAME,

ADDRESS)

Uncle- Stas .Gdansk

RELATIONSHIP

Single

PERSONAL

DOCUMENTS

NUMBER PLACE OF ISSUE DATE OF ISSUE EXPIRY DATE

PASSPORT EP647930 Ukraine 7101 09/January/2013 09/January/2023 NATIONAL

SEAMAN’S BOOK

No No No No

OTHER

SEAMAN’S BOOK

0263856 Poland,Szczecin 09/ April/2014 09/ April/2019 USA VISA/TYPE No

HEALTH

CERTIFICATE

DATE OF

EXAMINATION

10/February/

2016

EXPIRY

DATE

10/February/

2018

DRUG&ALC

OHOL TEST

No

CERTIFICATES OF COMPETENCE / COURSES

NAME OF CERTIFICATE NUMBER ISSUED BY ISSED / DATE VALID Basic Safety Traning

Certificate

UMS-5425-

126485-

11145/2013

Szczecin 18/

September/2013

17/ September/2018

Certificate of

Proficiency in

Security-awareness

UMS-1350-

126485-

26376/2014

Szczecin 04/

December/2014

Valid indefinitely

Certificate of

Profeciency for

seafarers with

designated

security duties

UMS-1351-

126485-

26284/2014

Szczecin 04/

December/2014

Valid indefinitely

Certificate of

Training in Oil and

Chemiker Tanker

Familiarization

UMS-1337-

126485-

17530/2015

Szczecin 23/

November/2015

Valid indefinitely

LANGUAGES VERY GOOD GOOD SATISFACTORY POOR NONE

English

ENGLISH

Yes

Russian Yes

Ukrainian Yes

Polish

GERMAN

Yes

German Yes

EDUCATIONAL DETAILS

NAME OF SCHOOL / PLACE FROM TO TYPE OF DIPLOMA

Maritime University of Szczecin

2013 to today Engineer (Operation of the

engine room)

EMPLOYMENT PERIODS ON SHORE

NAME OF THE COMPANY FROM TO POSITION

Remontowa Shipbuilding S.A. 01 July/2014 25/ July /2014 Poland, Stocznia Gdańsk S.A. SEA SERVICE

NAME OF

VESSEL

FLAG

TYPE OF

VESSEL

SHIPOWNER RANK

SIGNED

ON

SIGNED

OFF

m/f Wolin Bahamy RO-RO Unity Line

Limited Sp. z o.o

Eng.Appr. 01/ January

/2015

29/

January/2015

m/s Nawigator

XXI

Polska The ship training-

research

AM Szcecin Eng.Appr. 30/

November/20

15

20/

December/2015

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