APPLICATION FORM
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APPLICATION FORM
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| Name: | Vladimir | ||||
| Surname: | Kozlov | ||||
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Date of Birth: |
21.04.1959 | ||||
| Place of Birth: | Zhitomir, Ukraine | ||||
| Permanent address: | Odessa, Ukraine | ||||
| Personal code: | 2166016274 | ||||
| Citizenship: | Ukraine | ||||
| Passport No.: | AT 681277 | ||||
| Date of issue: | 03.04.2001 | ||||
| Place of issue: | Odessa | ||||
| Valid untill: | 03.04.2011 | ||||
| Seaman's Book No.: | AB 012640 | ||||
| Date of issue: | 24.07.2001 | ||||
| Place of issue: | Odessa | ||||
| Valid untill: | 24.07.2006 | ||||
| Expiry date of U.S. visa: | NO | ||||
| vaccination for cholera valid untill: | - | ||||
| vaccination for yellow fever valid untill: | 20.03.2003 | ||||
| Date of last medical certificate: | 20.03.2003 | ||||
| Marital status: | Married: X | Single: | Divorced: | Widower: | |
| Next of kin: (name, pas. No) | Viktoriya Knizhnikova - wife | ||||
| Supported children under age of 18 | 1.Ludmila Kozlova - 22.08.1984 | ||||
| (name, surname, date of birth) | - | ||||
| Knowledge of English language: | Very good: | Good: | Satisfactory: | Fair X | Poor: |
Licences, grades, certificates:
|
Licence held/grade, certificate |
No. |
Authority |
Country |
Date of issue |
Expiry date |
| Certificate of competency AB |
22069 |
Odessa |
Ukraine |
28.01.02 |
28.01.07 |
| Endorsement STCW |
22069 |
Odessa |
Ukraine |
11.10.00 |
11.10.05 |
| Personal Sea Survival (A-VI/1) |
48388 |
Odessa |
Ukraine |
18.02.00 |
18.12.05 |
Sea service (during five last years):
|
Name of vessel |
Company |
HP/DWT |
Flag |
Type |
Position |
From |
To |
| "Adm..Nahimov" |
Bleck Sea Shipping Co |
--------- |
Russian |
passenger |
motorman |
03.07.80 |
30.12.82 |
| "Latviya" |
Bleck Sea Shipping Co |
--------- |
Russian |
passenger |
motorman |
29.11.83 |
12.04.84 |
| "Fedor Shalyapin" |
Bleck Sea Shipping Co |
--------- |
Russian |
passenger |
AB |
10.09.85 |
10.12.87 |
| "Maxim Gorkiy" |
Bleck Sea Shipping Co |
--------- |
Russian |
passenger |
AB |
12.06.88 |
07.10.90 |
| "Fedor Shalyapin" |
Bleck Sea Shipping Co |
--------- |
Ukraine |
passenger |
AB |
17.01.91 |
13.05.96 |
| "Captain Brasnibrada" | "Chernomortehflot" |
--------- |
Ukraine |
crane |
motorman |
21.08.96 |
present time |
Ready to work from: ANY TIME