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APPLICATION FORM |
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| Name: Mykhaylo | Surname: Khomukha | ||||||
| Date of birth: 17.01.1962 | Place of birth: Odessa | ||||||
| Permanent address: Odessa, Ukraine | |||||||
| Passport (OVIR): AM 940675 | Place of issue: Odessa | Date of issue: 23.10.2000 | Valid until: 23.10.2010 | ||||
| Seaman’s book: AB 332420 | Place of issue: Odessa | Date of issue: 19.04.2005 | Valid until: 19.04.2010 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Khomukha Olga, KE 456822 | ||||||
| Supported children under age of 18 | 1. Khomukha Alexandra, 21.03.1990 | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Satisfactory | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Cherson Marine College | AB | 36 | 21.12.1983 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
04107/2003/08 |
Odessa |
12.11.2003 |
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| Endorsement STCW |
04107/2003/08 |
Odessa |
28.12.2007 |
14.12.2012 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
95317/2007 |
Odessa |
14.12.2007 |
14.12.2012 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
54870/2007 |
Odessa |
14.12.2007 |
14.12.2012 |
| Advanced Fire Fighting |
48562/2007 |
Odessa |
14.12.2007 |
14.12.2012 |
| Carrying Dangerous & Hazardous Substances |
2000/2007 |
Odessa |
14.12.2007 |
14.12.2012 |
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Tanker Certificates |
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| Chemical Tanker (Advanced and Familiarization, A-V/1, p.2-7) |
LZ 03106B |
Odessa |
25.12.2007 |
25.12.2012 |
| LPG carrier (Advanced and Familiarization, A-V/1, p.2-7) |
LZ 03106B |
Odessa |
25.12.2007 |
25.12.2012 |
| Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7) |
LZ 03106B |
Odessa |
25.12.2007 |
25.12.2012 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| Magic Swan |
BGI, V.Ships |
28000 |
Bahamas |
Gen cargo |
AB |
29.11.2002 |
29.09.2003 |
| Magic Swan |
BGI, V.Ships |
28000 |
Bahamas |
Gen cargo |
AB |
01.11.2003 |
02.06.2004 |
| Magic Swan |
BGI, V.Ships |
28000 |
Bahamas |
Gen cargo |
AB |
03.09.2004 |
06.11.2004 |
| Magic Swan |
BGI, V.Ships |
28000 |
Bahamas |
Gen cargo |
Bosun |
06.11.2004 |
06.03.2005 |
| Magic Swan |
BGI, V.Ships |
28000 |
Bahamas |
Gen cargo |
AB |
28.04.2005 |
27.08.2005 |
| Magic Swan |
V.Ships |
28000 |
Bahamas |
Gen cargo |
Bosun |
27.08.2005 |
24.07.2006 |
| CEC Mistral |
V.Ships |
26000 |
Bahamas |
Gen cargo |
AB |
27.06.2007 |
30.11.2007 |
| Experience at sea:Since 1983 | Knowledge Personal Computer (Yes / No): | |||
| Medical Certificate | ¹ 00958 | Issued: 15.06.2007 | Place: Odessa | Exp.date: 15.06.2008 |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 14.09.2001 | |||
Ready to work from: any time