APPLICATION FORM
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APPLICATION FORM |
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| Name: Ivan | Surname: Furchak | ||||||
| Date of birth: 11.11.1956 | Place of birth: Ukraine | ||||||
| Permanent address: Odessa, Ukraine | |||||||
| Passport (OVIR): AM 973868 | Place of issue: Ukraine | Date of issue: 23.02.2000 | Valid until: 23.08.2010 | ||||
| Seaman’s book: AB 190343 | Place of issue: Ukraine | Date of issue: 18.10.2000 | Valid until: 15.03.2010 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Single | ||||||
| Next of kin: (name, pas. No) | . | ||||||
| Supported children under age of 18 | . | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Satisfactory | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Odessa Maritime State School | AB | . | 1975 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
00712/2008/08 |
Odessa |
06.08.2008 |
--- |
| Endorsement STCW |
00712/2008/08 |
Odessa |
06.08.2008 |
02.07.2013 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
LZ 107226B |
Odessa |
02.07.2008 |
02.07.2013 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
LZ 14692B |
Odessa |
02.07.2008 |
02.07.2013 |
| Liberian Seaman's book |
0801577 |
USA |
28.09.2007 |
28.09.2012 |
| Panama Seaman's book |
CT 39000 |
Manila |
31.01.2006 |
31.01.2011 |
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Tanker Certificates |
. |
. |
. |
. |
| Chemical Tanker (Advanced and Familiarization, A-V/1, p.2-7) |
LZ 10825B |
Odessa |
02.07.2008 |
02.07.2013 |
| LPG carrier (Advanced and Familiarization, A-V/1, p.2-7) |
LZ 10825B |
Odessa |
02.07.2008 |
02.07.2013 |
| Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7) |
LZ 10825B |
Odessa |
02.07.2008 |
02.07.2013 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| Sea Shell |
Barracuda Shipping Co |
2970 |
Malta |
Bulker |
AB |
15.01.2003 |
20.11.2003 |
| A.P. Star |
ASP-Seascot |
23900 |
St.Vincent |
Tanker |
AB |
09.02.2004 |
20.09.2004 |
| Akuadasu |
ASP-Seascot |
20459 |
St.Vincent |
Tanker |
AB |
04.05.2005 |
07.09.2005 |
| A.P. Star |
ASP-Seascot |
23900 |
St.Vincent |
Tanker |
AB |
26.10.2005 |
07.12.2005 |
| Silver Star |
V.Ships |
12000 |
Bahamas |
Ch.Tanker |
AB |
13.02.2006 |
31.03.2006 |
| Stolt Nanami |
V.Ships |
19930 |
Panama |
Ch.Tanker |
AB |
01.06.2006 |
21.01.2007 |
| Spring Bear |
Seatrade |
9860 |
Liberia |
Reefer |
AB |
05.08.2007 |
14.02.2008 |
| Experience at sea: Since 2003 | Knowledge Personal Computer (Yes / No): no | |||
| Medical Certificate | ¹ | Issued: | Place: | Exp.date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 19.01.2014 | |||
Ready to work from: any time