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APPLICATION FORM

 Name: Yaroslav  Surname: Furchak
 Date of birth: 30.08.1964  Place of birth: Ukraine
 Permanent address: Odessa, Ukraine
 Passport (OVIR): KC 186976  Place of issue: Ukraine  Date of issue: 11.08.1999  Valid until: 11.08.2009
 Seaman’s book: AB 190437  Place of issue: Odessa  Date of issue: 23.10.2000  Valid until: 31.01.2010
 Citizenship: Ukraine  Expiry date of U.S. visa:  
 Marital Status  Married
 Next of kin: (name, pas. No)  wife - Furchak Anzhela
 Supported children under age of 18  1. Ivan Furchak - 23.07.2003
 (name, surname, date of birth)  .
 Knowledge of English language  Good
 Education:  Qualification:  No Diploma:  Date of Issue:
 Odessa State Marine School   AB  .  10.09.1986

Certificates of STCW 78/95

No.

Place

Date of issue

Expiry date

 Certificate of competency

00662/2003/08

Odessa

04.03.2003

---

 Endorsement STCW

00662/2003/08

Odessa

08.08.2007

11.06.2012

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

LZ 04239B

Odessa

08.08.2007

11.06.2012

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

LZ 02522B

Odessa

08.08.2007

08.08.2012

 Advanced Fire Fighting

221247/2006

Odessa

01.02.2006

01.02.2011

 Carrying dangerous & hazardous cargo (B-V/4, B-V/5)

LZ 03060B

Odessa

22.08.2007

22.08.2012

 Cyprus Seaman's book 

CY 067463

Lemesos

17.06.2004

17.06.2014

 Antigua and Barbuda Seaman's book 

51066

Aveiro

27.07.2005

26.07.2010

Sea service (during five last years):

Name of vessel

COMPANY

DWT

Flag

Type

Position

From

To

 Corey 

 Indochine

36600

Hong Kong

Bulker

Bosun

17.03.2003

02.08.2003

 Forum Fiji II 

 Phonix Reederey

5875

Cyprus

Container

Bosun

29.04.2004

02.02.2005

 Sirius P. 

 .

3000

Ant&Barb

Bulker

Bosun

10.07.2005

21.12.2005

 Atamaca 

 Cateric Shipping Ltd

85937

Isle of Man

Bulker

Bosun

21.02.2006

17.05.2006

 Valencia Carrier 

 Del Monte

12400

Bahamas

Bulker

Bosun

24.09.2006

16.05.2007

 Okean Vita 

 Alpha Shipping SIA

16856

Malta

Bulker

Bosun

08.10.2007

18.06.2008

 Experience at sea: Since 1986  Knowledge Personal Computer (Yes / No): yes 
 Medical Certificate  ¹  Issued:  Place:  Exp.date:
 Vaccination for cholera valid until:  Vaccination for yellow fever valid until: 16.02.2016 

Ready to work from: any time 

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