APPLICATION FORM
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APPLICATION FORM |
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| Name: Yurii | Surname: Kazannikov | ||||||
| Date of birth: 14.08.1961 | Place of birth: Kherson | ||||||
| Permanent address: Kherson, Ukraine | |||||||
| Passport (OVIR): EA 296035 | Place of issue: Kherson | Date of issue: 08.10.2007 | Valid until: 08.10.2017 | ||||
| Seaman’s book: AB 293447 | Place of issue: Kherson | Date of issue: 29.11.2002 | Valid until: 07.11.2012 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Divorced | ||||||
| Next of kin: (name, pas. No) | son | ||||||
| Supported children under age of 18 | |||||||
| (name, surname, date of birth) | |||||||
| Knowledge of English language | Satisfactory | ||||||
| Education: | Qualification: | Date of Issue: | |||||
| Kherson Marine College | El. Engineer | 1990 | |||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
00545/2007/11 |
Kherson |
24.10.2007 |
--- |
| Endorsement STCW |
00545/2007/11 |
Kherson |
24.10.2007 |
24.10.2012 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
11743/MPS |
Kherson |
17.08.2007 |
17.08.2012 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
06304/MPS |
Kherson |
17.08.2007 |
17.08.2012 |
| Antigua & Barbuda Seaman's book |
38670 |
Antigua |
31.03.2004 |
29.10.2013 |
| Netherlands Antilles Seaman's book |
37889 |
N.Antilles |
28.03.2007 |
28.03.2012 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| Rebecca |
Intersee&Navirent Deutschland GmbH |
10500 |
Ant&Barb |
Multipurp |
AB |
23.08.2004 |
16.04.2005 |
| Xenia |
Intersee&Navirent Deutschland GmbH |
10500 |
Ant&Barb |
Multipurp |
AB |
25.08.2005 |
27.02.2006 |
| Rebecca |
Intersee&Navirent Deutschland GmbH |
10500 |
Ant&Barb |
Multipurp |
AB |
12.05.2006 |
25.10.2006 |
| Sofia |
Intersee&Navirent Deutschland GmbH |
5762 |
N.Antilles |
Dry cargo |
AB |
15.02.2007 |
27.07.2007 |
| Rebecca |
Intersee&Navirent Deutschland GmbH |
10500 |
Ant&Barb |
Multipurp |
Bosun |
10.12.2007 |
02.06.2008 |
| Alana |
Intersee&Navirent Deutschland GmbH |
5050 |
Ant&Barb |
Dry cargo |
Bosun |
07.11.2008 |
15.05.2009 |
| Julia |
Intersee&Navirent Deutschland GmbH |
5699 |
N.Antilles |
Multipurp |
Bosun |
12.08.2009 |
27.12.2009 |
| Experience at sea: Since 1985 | Knowledge Personal Computer (Yes / No): Yes | |||
| Medical Certificate | ¹ 001456 | Issued: 05.08.2009 | Place: Kherson | Exp.date: 05.08.2010 |
| Vaccination for cholera valid until: 26.06.2019 | Vaccination for yellow fever valid until: 26.06.2019 | |||