APPLICATION FORM
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APPLICATION FORM
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| Name: | Oleg | ||||
| Surname: | Koshelap | ||||
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Date of Birth: |
20. 06. 76 | ||||
| Place of Birth: | Odessa, Ukraine | ||||
| Permanent address: | 100/1, Korolyova Str. Apt. 71, Odessa, 65122, Ukraine | ||||
| Personal code: | 2793021054 | ||||
| Citizenship: | Ukraine | ||||
| Passport No.: | AX 273353 | ||||
| Date of issue: | 24.02.2003 | ||||
| Place of issue: | Odessa, Ukraine | ||||
| Valid untill: | 24.02.2013 | ||||
| Seaman's Book No.: | AB 260610 | ||||
| Date of issue: | 05.02.2003 | ||||
| Place of issue: | Odessa, Ukraine | ||||
| Valid untill: | 05.02.2008 | ||||
| Expiry date of U.S. visa: | NO | ||||
| vaccination for cholera valid untill: | - | ||||
| vaccination for yellow fever valid untill: | 05.09.2013 | ||||
| Date of last medical certificate: | 24.07.2003 | ||||
| Marital status: | Married: | Single: | Divorced: X | Widower: | |
| Next of kin: (name, pas. No) | wife - Tatyana Koshelap | ||||
| Supported children under age of 18 | 1.son - Maksim Koshelap 16.12.1994 | ||||
| (name, surname, date of birth) | - | ||||
| Knowledge of English language: | Very good: | Good: | Satisfactory: | Fair X | Poor: |
Licences, grades, certificates:
|
Licence held/grade, certificate |
No. |
Authority |
Country |
Date of issue |
Expiry date |
| Able Seaman Certificate |
00136/2003/03 |
"TRAINING AND CERTIFYING- |
Ukraine |
20.02.2003 |
20.02.2008 |
| Endorsement |
00136/2003/03 |
-CENTRE SURVIVAL AT SEA- |
Ukraine |
20.02.2003 |
20.02.2008 |
| Proficiency in survival craft |
LZ 37712B |
-OF ODESSA" |
Ukraine |
24.06.2003 |
24.06.2008 |
| Oil Tanker Safety |
LZ 05804B |
"TRAINING AND CERTIFYING- |
Ukraine |
25.06.2003 |
25.06.2008 |
| "Safe use of self-contained - |
- |
-CENTRE SURVIVAL AT SEA- |
- |
- |
- |
| - breathing apparatus and equipment" |
LZ 03756B |
-OF ODESSA" |
Ukraine |
24.06.2003 |
24.06.2008 |
| Personal Sea Survival |
0033/2003 |
"TCCSS" |
Ukraine |
21.01.2003 |
21.01.2008 |
Sea service (during five last years):
|
Name of vessel |
Company |
HP/DWT |
Flag |
Type |
Position |
From |
To |
| "Cappadocia" | Kip-tur |
1900 |
Panama |
passenger |
O/S |
07.2003 |
08.2003 |
Ready to work from: any time