APPLICATION FORM
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APPLICATION FORM |
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| Name: Viktor | Surname: Tabachuk | ||||||
| Date of birth: 22.05.1965 | Place of birth: Kherson | ||||||
| Permanent address: Kherson, Ukraine | |||||||
| Passport (OVIR): ES 437026 | Place of issue: Kherson | Date of issue: 16.02.2006 | Valid until: 16.02.2016 | ||||
| Seaman’s book: AB 417870 | Place of issue: Kherson | Date of issue: 19.11.2008 | Valid until: 19.11.2013 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Tabachuk Svetlana | ||||||
| Supported children under age of 18 | Dmytro Tabachuk - 21.12.2005 | ||||||
| (name, surname, date of birth) | Dasha Tabachuk - 21.12.2005 | ||||||
| Knowledge of English language | Satisfactory | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Nikolaev Maritime School | AB | 23.04.1983 | |||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
00418/2007/07 |
Nikolaev |
06.07.2007 |
--- |
| Endorsement STCW |
00418/2007/07 |
Nikolaev |
06.07.2007 |
06.07.2012 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
05310/MPS |
Kherson |
08.06.2007 |
08.06.2012 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
03421/MPS |
Kherson |
08.06.2007 |
08.06.2012 |
| Ship's cranedriver |
00001/2006/42/98 |
Nikolaev |
04.10.2006 |
04.10.2011 |
| Bahamas Seaman's book |
LON 71221 |
Bahamas |
17.10.2006 |
--- |
| Cyprus Seaman's book |
CY 123143 |
Limassol |
04.10.2006 |
04.10.2011 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| Julie Delmas |
Delmas |
26061 |
Nassau |
Container |
AB/Crane driver |
23.05.2005 |
24.11.2005 |
| Kumasi |
Delmas |
26061 |
Nassau |
Container |
AB/Crane driver |
20.03.2006 |
20.09.2006 |
| Marie Delmas |
Delmas |
26061 |
Nassau |
Container |
AB/Crane driver |
12.12.2006 |
23.05.2007 |
| Nicolas Delmas |
CMA CGM |
26061 |
Nassau |
Container |
AB/Crane driver |
05.09.2007 |
05.02.2008 |
| Nicolas Delmas |
CMA CGM |
26061 |
Nassau |
Container |
AB/Crane driver |
24.03.2008 |
26.09.2008 |
| Kumasi |
CMA CGM |
26061 |
Nassau |
Container |
AB/Crane driver |
26.01.2009 |
20.08.2009 |
| Experience at sea: Since 1995 | Knowledge Personal Computer (Yes / No): Yes | |||
| Medical Certificate | ¹ | Issued: | Place: | Exp.date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 2015 | |||