APPLICATION FORM

 Name: Maxim  Surname: Chernyshev
 Date of birth: 23.11.1980  Place of birth: Kaliningrad
 Permanent address: Kaliningrad, Russia
 Passport (OVIR): 70 1265679  Place of issue: Kaliningrad  Date of issue: 01.09.2008  Valid until: 01.09.2013
 Seaman’s book: MF 0271583  Place of issue: Kaliningrad  Date of issue: 03.10.2008  Valid until: 03.10.2013
 Citizenship: Russia  Expiry date of U.S. visa: NO
 Marital Status  Single
 Next of kin: (name, pas. No)  
 Supported children under age of 18  
 (name, surname, date of birth)  
 Knowledge of English language  Good
 Education:  Qualification:  Date of Issue:
 Kaliningrad Marine College   Electrician  19.09.2009

 Certificates of STCW 78/95

 No.

 Place

 Date of issue

 Expiry date

 Certificate of competency  1044409257  Kaliningrad

19.09.2009

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 Endorsement STCW  1044409257  Kaliningrad

19.09.2009

19.09.2014

 Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1)  185398  Kaliningrad

29.09.2008

29.09.2013

 Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2)  150627  Kaliningrad

29.09.2008

29.09.2013

Sea service (during five last years):

Name of vessel

Company

DWT

Flag

Type

Position

From

To

 Orion  VSM Nordvegr Ltd  2035  Gibraltar  Container

Electrician

18.02.2009

12.06.2009

 Experience at sea: Since 2009

 Knowledge Personal Computer (Yes / No): Yes 
 Medical Certificate # 003152   Issued: 14.11.2008  Place: Kaliningrad  Exp.date: 14.11.2010
 Vaccination for cholera valid until:  Vaccination for yellow fever valid until: 19.12.2018