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APPLICATION FORM |
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| 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 | ||||
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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