APPLICATION FORM
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APPLICATION FORM |
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| Name: Igor | Surname: Dubinyak | ||||||
| Date of birth: 01.05.1969 | Place of birth: Mariupol | ||||||
| Permanent address: Mariupol, Ukraine | |||||||
| Passport (OVIR): PO 267827 | Place of issue: Donetsk | Date of issue: 08.08.2007 | Valid until: 08.08.2017 | ||||
| Seaman’s book: AB 386098 | Place of issue: Mariupol | Date of issue: 14.04.2008 | Valid until: 14.04.2013 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: 03.09.2012 | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Dubinyak Irina | ||||||
| Supported children under age of 18 | 1. Irina Dubinyak, 25.11.1991 | ||||||
| (name, surname, date of birth) | |||||||
| Knowledge of English language | Good | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Mariupol Marine School | Fitter-welder | 17.04.2004 | |||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 00159/2003/06 | Mariupol |
16.08.2007 |
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| Endorsement STCW | 00159/2003/06 | Mariupol |
16.08.2007 |
20.06.2012 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) | 08453-AS | Mariupol |
20.06.2007 |
20.06.2012 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 05721-AS | Mariupol |
22.06.2007 |
22.06.2012 |
| Cyprus Seaman's book | CY 078037 | Limassol |
31.01.2005 |
30.01.2015 |
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Tanker Certificates |
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| Chemical Tanker (Advanced and Familiarization, A-V/1, p.2-7) | 0318-AS | Mariupol |
27.06.2007 |
27.06.2012 |
| LPG carrier (Advanced and Familiarization, A-V/1, p.2-7) | 0318-AS | Mariupol |
27.06.2007 |
27.06.2012 |
| Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7) | 0318-AS | Mariupol |
27.06.2007 |
27.06.2012 |
Sea service (during five last years):
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Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Bagi | Diamant | 95000 |
Panama |
Tanker |
Fitter-welder |
25.11.2006 |
20.06.2007 |
| Adam | Veniera Shipping Co | 12429 |
Kingstown |
Refrigerator |
Fitter-welder |
20.09.2007 |
16.02.2008 |
| CMA CGM Kalamata | Geoffrey Shipholding | 37134 |
Greece |
Container |
Fitter-welder |
25.06.2008 |
18.02.2009 |
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Experience at sea: Since 2006 |
Knowledge Personal Computer (Yes / No): | |||
| Medical Certificate | Issued: | Place: | Exp.date: | |
| Vaccination for cholera valid until: | Vaccination for yellow fever | |||
Ready to work from: any time