APPLICATION FORM
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APPLICATION FORM |
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| Name: Yevgen | Surname: Kosenko | ||||||
| Date of birth: 23.07.1960 | Place of birth: Russia | ||||||
| Permanent address: Nikolaev, Ukraine | |||||||
| Passport (OVIR): AH 557675 | Place of issue: Nikolaev | Date of issue: 15.08.2000 | Valid until: 15.08.2010 | ||||
| Seaman’s book: AB 291450 | Place of issue: Nikolaev | Date of issue: 28.02.2005 | Valid until: 28.02.2010 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Kosenko Ludmila - EO 345367 | ||||||
| Supported children under age of 18 | . | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Satisfactory | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| College | Ship's welder | 00321/2003/07 | 24.10.2003 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 00321/2003/07 | Odessa |
24.10.2003 |
20.10.2008 |
| Endorsement STCW | 00321/2003/07 | Odessa |
24.10.2003 |
20.10.2008 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) | 54428B | Odessa |
14.10.2003 |
14.10.2008 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 54428B | Odessa |
14.10.2003 |
14.10.2008 |
| Ro-Ro Passenger ships (A-V/2) | 54428B | Odessa |
14.10.2003 |
14.10.2008 |
| Passenger ships other than Ro-Ro (A-V/3) | 54428B | Odessa |
14.10.2003 |
14.10.2008 |
Sea service (during five last years):
|
Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| 1. Galina IV | UMA Caalbye | 7904/15858 | Phnom Penh | Dry Cargo | Welder |
02.04.2001 |
22.08.2002 |
| 2. Zarina III | UMA Caalbye | 7904/15858 | Phnom Penh | Dry Cargo | Welder |
10.04.2002 |
25.12.2002 |
| 3. Galina IV | UMA Caalbye | 7904/15858 | Phnom Penh | Dry Cargo | Welder |
03.03.2003 |
15.01.2004 |
| 4. Lady Juliet | UMA Caalbye | 7904/15858 | St. Vincent | Dry Cargo | Welder |
25.03.2004 |
23.12.2004 |
| 5. Galina IV | UMA Caalbye | 7904/15858 | St. Vincent | Dry Cargo | Welder |
31.03.2005 |
17.09.2005 |
| 6. Elizaveta | Ukraine | 7904/14750 | St. Vincent | Dry Cargo | Welder |
10.11.2005 |
20.02.2005 |
| 7. Ocean Starlet | UMA Caalbye | 7904/15858 | St. Vincent | Dry Cargo | Welder |
17.04.2006 |
12.07.2006 |
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Experience at sea: Since 1996 |
Knowledge Personal Computer (Yes / No): No | |||
| Medical Certificate 21.071 | Issued: 06.11.2006 | Place: | Exp.date: 06.11.2007 | |
| Vaccination for cholera valid until: | Vaccination for yellow fever 24.02.2010 | |||
Contract till: 2008