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APPLICATION FORM

 Name: Volodymyr  Surname: Garkusha
 Date of birth: 24.05.1959  Place of birth: Dnepropetrovsk Reg., Ukraine
 Permanent address: Odessa, Ukraine
 Passport (OVIR): AK 258170  Place of issue: Odessa  Date of issue: 27.12.2004  Valid until: 27.12.2014
 Seaman’s book: AB 117693  Place of issue: Odessa  Date of issue: 26.09.1997 V alid until: 26.09.2007
 Citizenship: Ukraine  Expiry date of U.S. visa: NO
 Marital Status  Married
 Next of kin: (name, pas. No)  wife - Trubka Lyudmila
 Supported children under age of 18  --
 (name, surname, date of birth)  --
 Knowledge of English language  poor
 Education:  Qualification:  No Diploma:  Date of Issue:
 Odessa Marine School  motorman  1417  06.1984

Certificates of STCW 78/95

No.

Place

Date of issue

Expiry date

 Certificate of competency  040 IL

Illichevsk

19.09.2003

19.09.2008

 Endorsement STCW  040 IL

Illichevsk

19.09.2003

19.09.2008

 Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1)  35234

Odessa

13.01.2004

13.01.2009

 Crowd Management (A-V/3)  LZ 04148B

Odessa

19.06.2003

19.06.2008

 Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2)  LZ 36977B

Odessa

19.06.2003

19.06.2008

Sea service (during five last years):

Name of vessel

COMPANY

DWT/HP

Flag

Type

Position

From

To

 Taras Shevchenko

Antarctica

21000/21000

Ukraine

passanger

motorman

1984

2004

 Experience at sea: Since 1984  Knowledge Personal Computer (Yes / No):
 Medical Certificate  Issued: 28.12.2004  Place: Odessa  Exp.date: 28.12.2005
 Vaccination for cholera valid until:  Vaccination for yellow fever valid until:

Ready to work from:  ANY TIME

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