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APPLICATION FORM

 Name: Akif  Surname: Gadisov
 Date of birth: 08.11.1986  Place of birth: Nikolaev
 Permanent address: Nikolaev, Ukraine
 Passport (OVIR): EA 384448   Place of issue: Nikolaev  Date of issue:  Valid until:
 Seaman’s book:  Place of issue:   Date of issue:   Valid until:
 Citizenship: Ukraine  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  Satisfactory
 Education:  Qualification:  No Diploma:  Date of Issue:
 National University of shipbuilding   Bachelor from ship power Installations  .  01.06.2007
 Nikolaev Center of seafarer's training   motorman  .  22.07.2008

 Certificates of STCW 78/95

No.

Place

Date of issue

Expiry date

 Certificate of competency  00286/2008/07  Nikolaev

22.07.2008

---

 Endorsement STCW  00286/2008/07  Nikolaev

22.07.2008

02.04.2013

 Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1)  06015/2008/42/01  Nikolaev

02.04.2008

02.04.2013

 Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2)  04716/2008/42/02  Nikolaev

02.04.2008

02.04.2013

Sea service (during five last years):

Name of vessel

Company

DWT

Flag

Type

Position

From

To

 OM101  Ukrrechflot  119  Ukraine  Passenger

motorman

05.05.2008

07.07.2008

 Experience at sea: Since 2008   Knowledge Personal Computer (Yes / No): Yes 
 Medical Certificate  ¹ BCA-530  Issued: 07.07.2008  Place: Nikolaev  Exp.date: 07.07.2009
 Vaccination for cholera valid until:  Vaccination for yellow fever valid until: 

Ready to work from:  any time

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