APPLICATION FORM
|
|
APPLICATION FORM |
|
| Name: Roman | Surname: Kolontay | ||||||
| Date of birth: 01.07.1980 | Place of birth: Odessa | ||||||
| Permanent address: Razdelnaya, Odessa reg., Ukraine | |||||||
| Passport (OVIR): EA 404596 | Place of issue: Odessa | Date of issue: 13.11.2007 | Valid until: 13.11.2017 | ||||
| Seaman’s book: AB 367652 | Place of issue: Odessa | Date of issue: 07.12.2007 | Valid until: 07.12.2012 | ||||
| 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: | Date of Issue: | |||||
| Odessa Marine Training Centre | AB | 17.09.2009 | |||||
|
Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
01423/2009/08 |
Mariupol |
26.10.2009 |
--- |
| Endorsement STCW |
01423/2009/08 |
Mariupol |
26.10.2009 |
17.09.2014 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
1261/2009 |
Odessa |
23.09.2009 |
23.09.2014 |
| Carrying dangerous & hazardous cargo (B-V/4, B-V/5) |
0415/2009 |
Odessa |
24.09.2009 |
24.09.2014 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
0860/2009 |
Odessa |
24.09.2009 |
24.09.2014 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| MSC Emirates |
Goldenport Shipmanagement Ltd |
11312 |
Malta |
Container |
OS |
28.02.2008 |
05.11.2008 |
| Marie Paule |
Goldenport Shipmanagement Ltd |
54279 |
Malta |
Bulk carrier |
OS |
14.01.2009 |
18.08.2009 |
| Experience at sea: Since 2008 | Knowledge Personal Computer (Yes / No): Yes | |||
| Medical Certificate | ¹ | Issued: | Place: | Exp.date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 21.02.2018 | |||