APPLICATION FORM
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APPLICATION FORM |
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| Name: | Mykola | ||||
| Surname: | Brodnytsky | ||||
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Date of Birth: |
11.12.1964 | ||||
| Place of Birth: | Dnepropetrovsk, Ukraine | ||||
| Permanent address: | Dnepropetrovsk, Ukraine | ||||
| Personal code: | 2372116855 | ||||
| Citizenship: | Ukraine | ||||
| Passport No.: | AE - 148025 | ||||
| Date of issue: | 30.09.1998 | ||||
| Place of issue: | Dnepropetrovsk | ||||
| Valid untill: | 30.09.2008 | ||||
| Seaman's Book No.: | AB - 063924 | ||||
| Date of issue: | 29.10.1998 | ||||
| Place of issue: | Ilichivsk | ||||
| Valid untill: | 20.08.2008 | ||||
| Expiry date of U.S. visa: | 24.07.2004 | ||||
| vaccination valid untill: | - | ||||
| for cholera: | 12.06.2002 | ||||
| for yellow fever: | 11.07.2002 | ||||
| Date of last medical certificate: | 11.07.2002 | ||||
| Marital status: | Married: X | Single: | Divorced: | Widower: | |
| Next of kin: (name, pas. No) | wife - Brodnytskaya Lubov | ||||
| Supported children under age of 18 | 1. NO | ||||
| (name, surname, date of birth) | - | ||||
| Knowledge of English language: | Very good: | Good: X | Satisfactory: | Fair | Poor: |
Licences, grades, certificates:
|
Licence held/grade, certificate |
No. |
Authority |
Country |
Date of issue |
Expiry date |
| Qualified motorman |
00561 |
Illichivsk |
Ukraine |
23.09.2003 |
23.09.2008 |
| Endorsement motorman |
00561 |
OMTS |
Ukraine |
23.09.2003 |
23.09.2008 |
| Ship's Welder |
00939 |
Illichivsk |
Ukraine |
23.09.2003 |
23.09.2008 |
| Endorsement Welder |
00939 |
OMTS |
Ukraine |
23.09.2003 |
23.09.2008 |
| Survival Craft |
3135 |
OMTS |
Ukraine |
08.09.2003 |
08.09.2008 |
| Personal Survival Techniques |
1438 |
OMTS |
Ukraine |
11.08.2003 |
11.09.2008 |
| Cert. A-V/1. STCW - 78 |
0687 |
OMTS |
Ukraine |
11.08.2003 |
11.09.2008 |
Sea service (during five last years):
|
Name of vessel |
Company |
HP/DWT |
Flag |
Type |
Position |
From |
To |
| Marneuli | Blasco |
9600/20000 |
Ukraine |
cargo |
oiler |
12.1987 |
02.1994 |
| Toivo Antikainen | Blasco |
9600/20000 |
Ukraine |
cargo |
oiler |
07.1994 |
02.1995 |
| Djuzeppe di Vittorio | Blasco |
9600/18000 |
Ukraine |
cargo |
oiler |
06.1995 |
04.1996 |
| Vinnitsa | Blasco |
9600/22000 |
Ukraine |
LO-RO |
oiler |
06.1996 |
03.1997 |
| Fulvia | Franser Snip. |
9600/18000 |
Panama |
cargo |
oiler |
06.1997 |
04.1998 |
| Achilleas | Danaos |
13600/35879 |
Panama |
bulker |
welder |
21.08.2002 |
30.05.2003 |
Ready to work from: ANY TIME