BERNHARD SCHULTE SHIPMANAGEMENT

CREW SERVICE CENTER (UKRAINE) LIMITED

PERSONNEL APPLICATION FORM

Filing does not guarantee employment

Position applied for : Engine cadet

Second choice ( if any ) : ---

Personal data

Name : Oleksii Silchenko

Marital status (single, married, divorced):

Date of birth : 26.08.2001

Number of children (under 18 years) : ---

Place of birth : Odessa

Next of kin:

Religion (Christian, mos., etc.) : ---

Relationship : +

Nationality : Ukrainian

Address :

Address : Itskhaka Rabina St 4

Telephone :

Telephone: +380*********

Zip code: ---

Pre-sea education and year of graduation: National University”Odessa Maritime Academy”(currently 3nd year cadet):01.09.2018-until present

Diploma No :

Document No

Date of issue

Expiry date

Seaman’s Identification Card

AB 641192

15.08.2019

15.08.2024

Civil Travel Passport

FZ111748

15.07.2020

15.07.2030

Medical certificates

Date of issue

Expiry date

Medical Certificate

Colour of eyes : brown

Yellow fever

Colour of hair : brown

Drug & alcohol test

Height : 180 cm

Cholera

Weight : 82 kilo

SEA SERVICE

Period on board

Vessel’s

name

Year built

DWT

Vessel

type

BHP

Type of engine

Flag

Company

Rank

From

To

Remarks: SETS English – SETS Professional - Visa USA - D.O.A - Last wage -

Name : Oleksii Silchenko Position applied for : Engine cadet

STCW Certificates

Document

Grade

Certif. No

Issued on/at

Expiry

Document

Grade

Certif. No

Issued on/at

Expiry

Certif. of Competency

Bridge / Engine Team

Endorsement

Ship’s Handling

GOC / GMDSS

LICOS

GMDSS Endorsement

ECDIS

ARPA

AMOS

Basic Safety

170762

21.07.2020

21.07.2025

ISM Code / SMS

Prof. in Survival Craft

Ship’s Security Officer

Adv. Fire Fighting

Ship’s Safety Officer

Med. First Aid / Care

Risk Assessment

Hazardous Materials

Other (please list)

DCE

Security Duties

- // - LPG Specialized

Security Awareness

7521/20061946

07.06.2019

07.06.2024

- // - Oil and Chem Basic

170855

23.07.2020

23.07.2025

Security Related

Safety Familiarization

10240/20061924

07.06.2019

07.06.2024

Other seaman’s books and licenses

Country of Flag State

Grade

Document

No

Date of

Issue

Expiry

Date

Country of Flag State

Grade

Document

No

Date of

Issue

Expiry

Date

Please complete the following for references

Company

Tel.

Company

Tel.

Address

Address

I understand and agree that my contract will be terminated without prejudice if any of submitted details are voted as false.

Personal information regarding myself may be shared for operational reasons within the companies of the BSM group

And with concerned Ship Owner(s).

Applicant’s Signature :

Date :

FOR OFFICE USE ONLY:

Level of English :

Good

+

Average

Poor

NOTES :

Working clothes

Height: Collar: Trousers:

Overall: Shoes : Sweater:

Contact this candidate