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APPLICATION FORM |
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| Name: Yuriy | Surname: Lapunko | ||||||
| Date of birth: 23.05.1978 | Place of birth: Kaliningrad | ||||||
| Permanent address: Sevastopol, Ukraine | |||||||
| Passport (OVIR): AN 682860 | Place of issue: Sevastopol | Date of issue: 28.04.2001 | Valid until: 26.04.2011 | ||||
| Seaman’s book: AB 008101 | Place of issue: Sevastopol | Date of issue: 30.03.2000 | Valid until: 30.03.2010 | ||||
| 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: | ||||
| Sevastopol Navy Marine Institute | . | . | 1998 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency (welder) | 00082/2005/09 | Sevastopol |
04.08.2005 |
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| Endorsement STCW (welder) | 00082/2005/09 | Sevastopol |
08.06.2007 |
10.09.2009 |
| Certificate of competency (AB) | 00466/2006/10 |
Sevastopol |
13.06.2006 |
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| Endorsement STCW (AB) | 00466/2006/10 | Sevastopol |
11.06.2007 |
12.07.2010 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) | 0365/2005 | Sevastopol |
12.07.2005 |
12.07.2010 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 00508C | Sevastopol |
12.05.2006 |
13.05.2011 |
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Tanker Certificates |
. |
. |
. |
. |
| Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7) | 02910C | Sevastopol |
25.05.2007 |
25.05.2012 |
Sea service (during five last years):
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Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Muzestveny | . |
. |
Ukraine |
Ocean tug |
AB |
2001 |
2004 |
| Ecotech | . |
. |
Ukraine |
Cable vessel |
welder |
2005 |
2007 |
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Experience at sea: Since 2001 |
Knowledge Personal Computer (Yes / No): no | |||
| Medical Certificate | Issued: | Place: | Exp.date: 01.11.2008 | |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 19.01.2009 | |||
Ready to work from: 23.11.2007