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APPLICATION FORM |
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| Name: Vadym | Surname: Gayduchenko | ||||||
| Date of birth: 19.01.1984 | Place of birth: Kherson, Ukraine | ||||||
| Permanent address: Kherson, Ukraine | |||||||
| Passport (OVIR): EA 153821 | Place of issue: Kherson | Date of issue: 22.08.2007 | Valid until: 22.08.2017 | ||||
| Seaman’s book: AB 361385 | Place of issue: Kherson | Date of issue: 06.06.2007 | Valid until: 06.06.2012 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Tatyana Gayduchenko | ||||||
| Supported children under age of 18 | Elizaveta Gayduchenko, 21.09.2006 | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Good | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Nikolaev Seafarers' Training Centre | AB | . | 27.04.2007 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
00188/2007/07 |
Nikolaev |
27.04.2007 |
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| Endorsement STCW |
00188/2007/07 |
Nikolaev |
27.04.2007 |
27.04.2012 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
03352/2007/42/01 |
Nikolaev |
25.04.2007 |
25.04.2012 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
02365/2007/42/02 |
Nikolaev |
25.04.2007 |
25.04.2012 |
| Hazardous Cargoes |
02365/2007/42/02 |
Nikolaev |
25.04.2007 |
25.04.2012 |
Sea service (during five last years):
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Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| Nikolaev |
Orenburg Gazprom |
2991 |
Russia |
Dry cargo |
AB |
10.11.2005 |
20.11.2006 |
| Nicolas Delmas |
Delmas |
30453 |
Bahamas |
Container |
AB |
13.08.2008 |
25.01.2009 |
| Experience at sea: Since 2005 | Knowledge Personal Computer (Yes / No): | |||
| Medical Certificate | ¹ | Issued: | Place: | Exp.date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 23.11.2017 | |||
Ready to work from: any time