MSC CREWING SERVICES

MSC House, **-v Lustdorfskaya road, Odessa 65088, Ukraine

Tel.: +38 (0482) 333 891

Fax.: +38-048-****-*** / E-mail: adwlu5@r.postjobfree.com

APPLICATION FORM

(Personal Data)

Position applied for License hold Date Available

Family Name: Hermanovych

Name: Roman

Father's name: Yurievych

Date of birth: 21.04.1989

Place of birth: Kherson Ukraine

Nationality: Ukraine

Marital status: Unmarried

Address: Kherson, Stroiteley str. h.11 fl.66

Nearest Airport:

Home phone:

E-mail: adwlu5@r.postjobfree.com

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

Next of kin and relationship:

Children (name & DOB): Sofia

Next of kin’s address:

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

Inter. P’port No : FZ686373

Date of issue: 15.12.2020

Valid: 15.12.2030

Place of issue: 6512

Seaman's book No : AB 563832

Date of issue: 25.09.2015

Valid: 29.05.2025

Place of issue: Port Kherson

Civil P’port No : MP 137913

Date of issue: 25.05.2005

Place of issue: Ukraine

USA visa No :

Date of issue:

Valid:

Place of issue:

TOSE :

Date of issue:

MARLINS, %:

Date of issue:

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

“DELTA”

1982

Concorse corporation

Saint Kitts & Nevis

General cargo

3330

OS

03.06.2016

02.04.2017

“BELLATRIX”

1978

ISBIR Shipping ltd

Russia

General cargo

2893

OS

29.11.2017

03.06.2018

“SILVER LION”

2005

Lion Marine ltd

Antigua Barbuda

General cargo

6315

OS

16.12.2018

30.07.2019

“TRANSPACIFIC”

2009

Sand One Holdings Limit

Liberia

Bulk Carr

22941

OS

29.12.2020

19.07.2021

“MSC AINO”

2019

FPG Ship holding Liberia 17 S.A.

Liberia

Container

112695

OS

10.11.2021

10.07.2022

Name of Maritime Institution attended

Address of institution

From

To

Degree of Diploma

STCW Certificates

Number

Issued

Valid

Place of issue

STCW Certificates

Number

Issued

Valid

Place of issue

Certificate of competency

002449

25.08.2015

-

AVANT

BRM or ERRM Course

Endorsement

13916/2015/11

15.10.2015

-

PORT OF KHERSON

Personal safety

015662

20.10.2020

20.10.2025

NIKOLAEV CENTRE OF TRAINING

GMDSS Endorsement

Advanced fire fighting

27/2020/312

22.12.2020

22.12.2025

ALFA-TRAINING

Radar observer

Prof. in survival craft

285922

20.10.2020

20.10.2025

NIKOLAEV CENTRE OF TRAINING

ARPA

Survival / fast rescue boat

AIS course

Medical first aid

ECDIS course

Medical care

Security officer (ISPS)

Hazardous cargoes

7/2020/247

18.12.2020

18.12.2025

ALFA-TRAINING

Security Designated Duties

242528

20.10.2020

20.10.2025

NIKOLAEV CENTRE OF TRAINING

Training pers on pass.ships

Safety officer (ISM)

Security-Related for all seafarers

239526

20.10.2020

20.10.2025

NIKOLAEV CENTRE OF TRAINING

Medical examination

Issued:

Valid:

Weight, kg:90

Height, cm:187

Drug & alcohol test

Issued:

Valid:

Eyes:Gray

Hair:Light brown

Yellow fever

Issued:20.11.2015

Valid:20.11.2025

Overall size:54

Safety shoes:44

Another States Seamen’s Books

Rank

Document No

Issued

Valid

Another States Certificates of competency

Rank

Document No

Issued

Valid

Liberia

OS

1574373

20.01.2021

20.01.2026

Liberia

Panama

Panama

Please complete addresses of your previous employers for references

Company

Tel

Company

Tel

Address

Address

Мій підпис підтверджує мою остаточну та безсуперечну згоду на обробку (збір, накопичення, зберігання, прийняття, систематизацію, використання, розподіл, поновлювання, змінення, знищення, кодування та будь-які інші дії, необхідні для надавання посередницьких послуг з найму за кордоном і/або інших супровідних послуг) моїх особистих даних, що вказано в цій заявці з найму, а також будь-яких інших моїх особистих даних, що надаються до ТОВ «ЕМ ЕС СІ КРЮЇНГ СЕРВІСЕС»

Signature Date I understand, that my working contract will be canceled without notifying if any of submitted information and documents are voted as false.

Nationalities of crew sailed with:

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