APPLICATION FORM
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APPLICATION FORM |
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| Name: Serhiy | Surname: Kopytsa | ||||||
| Date of birth: 26.07.1969 | Place of birth: Zaporozhye | ||||||
| Permanent address: Zaporozhye, Ukraine | |||||||
| Passport (OVIR): EA 297011 | Place of issue: Ilyichevsk | Date of issue: 08.10.2007 | Valid until: 08.10.2017 | ||||
| Seaman’s book: AB 301161 | Place of issue: Ilyichevsk | Date of issue: 01.11.2006 | Valid until: 01.11.2011 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Kopytsa Aleksandra, CA 103856 | ||||||
| Supported children under age of 18 | 1. Kopytsa Margarita - 04.07.1992 | ||||||
| (name, surname, date of birth) | 2. Kopytsa Kirill - 26.07.1998 | ||||||
| Knowledge of English language | Satifactory | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Zaporozhye River School | AB/Motorman | 215279 | 18.07.1987 | ||||
| Azov-Safety Training Mariupol | 1-st motorman | 000528-AST | 28.11.2006 | ||||
| Azov-Safety Training Mariupol | AB | 000527-AST | 21.11.2006 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency (AB) |
00473/2006/06 |
Mariupol |
28.11.2006 |
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| Endorsement STCW (AB) |
00473/2006/06 |
Mariupol |
28.11.2006 |
28.11.2011 |
| Certificate of competency (motorman) |
00231/2006/06 |
Mariupol |
28.11.2006 |
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| Endorsement STCW (motorman) |
00231/2006/06 |
Mariupol |
28.11.2006 |
28.11.2011 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
17041-AS |
Mariupol |
28.11.2006 |
28.11.2011 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
08878-AS |
Mariupol |
22.11.2006 |
22.11.2011 |
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Tanker Certificates |
. |
. |
. |
. |
| Chemical Tanker (Advanced and Familiarization, A-V/1, p.2-7) |
02059-AS |
Mariupol |
17.11.2006 |
17.11.2011 |
| LPG carrier (Advanced and Familiarization, A-V/1, p.2-7) |
02059-AS |
Mariupol |
17.11.2006 |
17.11.2011 |
| Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7) |
02059-AS |
Mariupol |
17.11.2006 |
17.11.2011 |
| Cargo Equipment on Tankers (A-V/1, paragraph 1) |
02059-AS |
Mariupol |
17.11.2006 |
17.11.2011 |
| Carriage of dangerous & hazardous substances |
04160-AS |
Mariupol |
24.11.2006 |
24.11.2011 |
| Breathing apparatus |
17041-AS |
Mariupol |
23.11.2006 |
23.11.2011 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| Delmas Surkouf |
Port Vendres Maritime S.A. |
22312 |
Bahamas |
Container |
AB |
20.12.2004 |
22.08.2005 |
| Energy Ranger |
Verizon Marine LTD |
49950 |
Isle of man |
Bulk carrier |
AB |
07.02.2006 |
19.09.2006 |
| Bellatrix |
Balimar Shipping LTD |
5566 |
Ant&Barb |
Gen. Cargo |
AB |
03.05.2007 |
17.10.2007 |
| Tiger Creek |
Askoldas Ltd |
9823 |
Marshall isl. |
Container |
motorman |
02.01.2008 |
05.07.2008 |
| Tim |
Interskan Schiffahrtsgesell |
5566 |
Limassol |
Gen. Cargo |
motorman |
17.09.2008 |
26.03.2009 |
| Experience at sea: Since 1987 | Knowledge Personal Computer (Yes / No): yes | |||
| Medical Certificate | ¹ 0167 | Issued: 21.08.2008 | Place: Odessa | Exp.date: 21.08.2009 |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: | |||
Ready to work from: any time