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APPLICATION FORM |
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| 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 | |||||
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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):
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Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Orion | VSM Nordvegr Ltd | 2035 | Gibraltar | Container |
Electrician |
18.02.2009 |
12.06.2009 |
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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 | |||