APPLICATION FORM

 Name: Mikhailo  Surname: Bolshakov
 Date of birth: 26.06.1958  Place of birth: Polosk, Belarus
 Permanent address: Odessa, Ukraine
 Passport (OVIR): EK 139422  Place of issue: Nikopol'  Date of issue: 21.04.2009  Valid until: 21.04.2019
 Seaman’s book: AB 407098  Place of issue: Odessa  Date of issue: 01.12.2009  Valid until: 01.12.2014
 Citizenship: Ukraine  Expiry date of U.S. visa: NO
 Marital Status  Divorced
 Next of kin: (name, pas. No)  
 Supported children under age of 18  
 (name, surname, date of birth)  
 Knowledge of English language  Satisfactory
 Education:  Qualification:  Date of Issue:
 Evpatoriya Marine School   AB-motorman  16.11.1981

Certificates of STCW 78/95

No.

Place

Date of issue

Expiry date

 Certificate of competency

00628/2006/03

Illichivsk

23.06.2006

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 Endorsement STCW

00628/2006/03

Illichivsk

16.04.2009

16.04.2014

 Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1)

1/464/09

Illichivsk

09.04.2009

09.04.2014

 Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2)

1/284/09

Illichivsk

07.04.2009

07.04.2014

 Advanced Fire Fighting

1/079/09

Illichivsk

18.05.2009

18.05.2014

 Hazardous Cargoes 

1/113/09

Illichivsk

01.04.2009

01.04.2014

Sea service (during five last years):

Name of vessel

COMPANY

DWT

Flag

Type

Position

From

To

 Midland 102 

 Azimut

3000

Malta

Bulker

Bosun

13.07.2006

14.10.2006

 Toulon

 Lumar

10000

Malta

Cargo

Bosun

10.04.2007

15.06.2007

 Alt.Lader

 Lumar

18000

Malta

Ro-Ro

Bosun

20.07.2007

22.01.2008

 Kursk

 Inmarko

10000

Malta

Reefer

Bosun

27.03.2008

16.06.2008

 Santana

 Intreco

50000

Malta

Bulker

AB

14.08.2008

19.03.2009

 Sepas

 Azimut

5000

Iran

Bulker

Bosun

04.07.2009

11.11.2009

 Experience at sea: Since 1991  Knowledge Personal Computer (Yes / No): Yes 
 Medical Certificate  ¹  Issued:  Place:  Exp.date:
 Vaccination for cholera valid until:  Vaccination for yellow fever valid until: