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APPLICATION FORM |
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| 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 | |||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
00628/2006/03 |
Illichivsk |
23.06.2006 |
--- |
| 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: | |||