APPLICATION FORM
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APPLICATION FORM |
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| Name: Yuriy | Surname: Borodin | ||||||
| Date of birth: 24.10.1961 | Place of birth: Kharkov Reg., Ukraine | ||||||
| Permanent address: Odessa, Ukraine | |||||||
| Passport (OVIR): AT 684983 | Place of issue: Odessa | Date of issue: 25.05.2001 | Valid until: 25.05.2011 | ||||
| Seaman’s book: AB 081227 | Place of issue: Odessa | Date of issue: 03.06.2002 | Valid until: 03.06.2007 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Anna Borodina - pass.# KE 795006 | ||||||
| Supported children under age of 18 | Vladislav Borodin - 14.10.1987 | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Poor | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Odessa Marine School | Able Seaman | 15789 | 21.06.1984 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
0443/2003 |
Odessa |
05.02.2003 |
05.02.2008 |
| Qualified seaman certificate |
1116/2003/08 |
Odessa |
02.04.2003 |
05.02.2008 |
| Endorsement STCW |
1116/2003/08 |
Odessa |
02.04.2003 |
05.02.2008 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
0240/2003 |
Odessa |
10.02.2003 |
10.02.2008 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
0379/2003 |
Odessa |
04.02.2003 |
04.02.2008 |
| Passenger ships other than Ro-Ro (A-V/3) |
0190/2001 |
Odessa |
05.06.2001 |
05.06.2006 |
| Safe use of seld-contained breathing apparatus and protective clothing & equipment |
01677 B |
Odessa |
06.06.2002 |
06.06.2007 |
| Certificate of Fire Man |
0037/2002 |
Odessa |
05.03.2002 |
05.03.2007 |
| Advanced Fire Fighting |
0328/2003 |
Odessa |
05.02.2002 |
05.02.2008 |
| Tanker Certificate |
0108/2003 |
Odessa |
05.02.2003 |
05.02.2008 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| 1. Olvia |
UMA |
15600 |
Ukraine |
pass |
Ch.Fire |
2003 |
2005 |
| 2. Assedo |
UMA |
19180 |
Ukraine |
pass |
Ch.Fire |
2001 |
2003 |
| 3. Olvia |
UMA |
15600 |
Ukraine |
pass |
Ch.Fire |
1998 |
2001 |
| 4. Karelia |
Blasco |
15600 |
Liberia |
pass |
AB |
1995 |
1998 |
| 5. Azerbaidzhan |
Blasco |
15600 |
Ukraine |
pass |
AB |
1992 |
1995 |
| Experience at sea: Since 1984 | Knowledge Personal Computer (Yes / No): | |||
| Medical Certificate | ¹ 011057 | Issued: 05.10.2004 | Place: Odessa | Exp.date: 05.10.2005 |
| Vaccination for cholera valid until: 29.07.2008 | Vaccination for yellow fever valid until: 12.11.2013 | |||
Ready to work from: any time