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APPLICATION FORM |
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| Name: Andrey | Surname: Konopelko | ||||||
| Date of birth: 24.09.1980 | Place of birth: Moldova | ||||||
| Permanent address: Odessa reg., Ukraine | |||||||
| Passport (OVIR): AM 942489 | Place of issue: Odessa | Date of issue: 09.11.2000 | Valid until: 09.11.2010 | ||||
| Seaman’s book: AB 07181324 | Place of issue: Odessa | Date of issue: 24.10.2000 | Valid until: 25.10.2009 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: 30.10.2011 | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Konopelko Alla | ||||||
| Supported children under age of 18 | . | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Good | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Training center of seafarers AVANT | seamen | . | 01.08.2013 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
04554/2003/08 |
Illichivsk |
24.12.2003 |
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| Endorsement STCW |
04554/2003/08 |
Illichivsk |
02.10.2008 |
02.10.2013 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
1/858/08 |
Illichivsk |
01.08.2008 |
01.08.2013 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
1/151/08 |
Illichivsk |
01.08.2008 |
01.08.2013 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| Hill |
Aptera |
23000 |
Liberia |
Dry cargo |
MB |
14.03.2003 |
10.09.2003 |
| IMME |
Aptera |
23000 |
Liberia |
Dry cargo |
OS |
17.03.2004 |
29.08.2004 |
| Souria |
Tritea |
17000 |
Cyprus |
Bulker |
OS |
28.01.2005 |
22.06.2005 |
| Souria |
Larus |
23000 |
Liberia |
Bulker |
AB |
06.10.2005 |
09.09.2006 |
| Lake Michigan |
Anglo-Eastern Group |
38000 |
Marshall |
Bulker |
OS |
19.12.2007 |
15.07.2008 |
| Experience at sea: Since 2002 | Knowledge Personal Computer (Yes / No): Yes | |||
| Medical Certificate | ¹ 000040 | Issued: 29.03.2002 | Place: Odessa | Exp.date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: | |||
Ready to work from: 17.10.2008