APPLICATION FORM
|
|
APPLICATION FORM
|
|
| Name: | Andriy | ||||
| Surname: | Kichuk | ||||
|
Date of Birth: |
16.02.54 | ||||
| Place of Birth: | Russia | ||||
| Permanent address: | 1, Frunze str., V. Antonovka, Kherson region, Ukraine | ||||
| Personal code: | 1977021910 | ||||
| Citizenship: | Ukraine | ||||
| Passport No.: | AC 433989 | ||||
| Date of issue: | 01.09.97 | ||||
| Place of issue: | Kherson, Ukraine | ||||
| Valid untill: | 01.09.07 | ||||
| Seaman's Book No.: | AB 083278 | ||||
| Date of issue: | 10.10.02 | ||||
| Place of issue: | Port of Ilyichevsk, Ukraine | ||||
| Valid untill: | 10.10.07 | ||||
| Expiry date of U.S. visa: | 12 dec 2007 | ||||
| vaccination valid untill for cholera: | . | ||||
| vaccin. valid untill for yellow fever: | . | ||||
| Date of last medical certificate: | 14.12.2003 | ||||
| Marital status: | Married: | Single: | Divorced: X | Widower: | |
| Next of kin: (name, pas. No) | Daughter - Kichuk Anastasiya, pas.# MO 837296 | ||||
| Supported children under age of 18 | 1.NO | ||||
| (name, surname, date of birth) | . | ||||
| Knowledge of English language: | Very good: | Good: X | Satisfactory: | Fair | Poor: |
Licences, grades, certificates:
|
Licence held/grade, certificate |
No. |
Authority |
Country |
Date of issue |
Expiry date |
| Bosun CERTIFICATE |
0502/2002 |
"TRAINING AND CERTIFYING- |
Ukraine |
05.11.2002 |
05.11.07 |
| Endorsement Bosun |
02836/2002/08 |
-CENTRE SURVIVAL AT SEA- |
Ukraine |
30.12.2002 |
30.12.07 |
| A-VI/I Basic Safety |
3067/2002 |
-OF ODESSA" |
Ukraine |
08.11.2002 |
08.11.07 |
| A-VI/I Advanced fire fight |
0451/2003 |
"TRAINING AND CERTIFYING- |
Ukraine |
06.11.2002 |
06.11.07 |
| A-VI/2 Proficiency in survival craft |
0398/200 |
-CENTRE SURVIVAL AT SEA- |
Ukraine |
01.11.2000 |
01.11.05 |
| Certificate AB |
2026/2002/05 |
-OF ODESSA" |
Ukraine |
05.11.2002 |
05.11.07 |
| B-V/4 B/5 Hazardovs Cargoes |
001371-KH |
Kherson |
Ukraine |
07.12.01 |
07.12.06 |
Sea service (during five last years):
|
Name of vessel |
Company |
HP/DWT |
Flag |
Type |
Position |
From |
To |
| PAMPERO | H&P |
3900 |
Antig. |
cont |
AB |
01.2003 |
08.2003 |
| PARANGA | H&P |
4200 |
Antig. |
cont |
AB |
12.2001 |
09.2002 |
| PANTERA | H&P |
6500 |
Antig. |
cont |
AB |
02.2001 |
09.2001 |
| Thalasini Axia | Avra |
167000 |
Cyprus |
bulcar |
Bosun |
12.1998 |
05.2000 |
| Ithaki | Magellan |
30000 |
Cyprus |
bulcar |
Bosun |
11.1997 |
08.1998 |
| Gannet | Sea Birds |
18000 |
Malta |
Drycarg |
Bosun |
06.1996 |
06.1997 |
Ready to work from: any time