APPLICATION FORM
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APPLICATION FORM |
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| Name: Sergiy | Surname: Maksimchuk | ||||||
| Date of birth: 25.08.1960 | Place of birth: Kerch, Ukraine | ||||||
| Permanent address: Kerch, Ukraine | |||||||
| Passport (OVIR): EK 482807 | Place of issue: Kerch | Date of issue: 11.09.2009 | Valid until: 11.09.2019 | ||||
| Seaman’s book: AB 392547 | Place of issue: Kerch | Date of issue: 19.01.2010 | Valid until: 19.01.2010 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Maksimchuk Sveta | ||||||
| Supported children under age of 18 | Maksimchuk Olga, 11.12.1995 | ||||||
| (name, surname, date of birth) | |||||||
| Knowledge of English language | Satisfactory | ||||||
| Education: | Qualification: | Date of Issue: | |||||
| Yeysk Marine College | mechanic | 1986 | |||||
| Kerch Marine College | Ship's welder | 2000 | |||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 00058/2002/04 | Kerch |
28.11.2002 |
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| Endorsement STCW | 00058/2002/04 | Kerch |
25.06.2007 |
15.06.2012 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) | 05665 KR | Kerch |
19.06.2007 |
18.06.2012 |
| Advanced Fire Fighting (A-VI/3) | 02179 KR | Kerch |
06.09.2007 |
05.09.2012 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 03840 KR | Kerch |
11.09.2009 |
11.09.2012 |
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Tanker Certificates |
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| Chemical Tanker (Advanced and Familiarization, A-V/1, p.2-7) | 00452B | Kerch |
15.06.2007 |
15.06.2012 |
| LPG carrier (Advanced and Familiarization, A-V/1, p.2-7) | 00452B | Kerch |
15.06.2007 |
15.06.2012 |
| Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7) | 00452B | Kerch |
15.06.2007 |
15.06.2012 |
Sea service (during five last years):
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Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Kap. Koval | Kerch Marine | 10000 | Litva | Reefer | fitter |
15.11.2005 |
23.02.2006 |
| Peleda | Kerch Marine | 12000 | Litva | Reefer | fitter |
23.02.2006 |
27.04.2006 |
| Gorgona | Kerch Marine | 6000 | Barbaros | Tanker | welder |
12.07.2006 |
12.03.2007 |
| Ngol Luena | ABC Maritime | 48000 | Malta | Tanker | fitter |
17.09.2007 |
17.03.2008 |
| Ngol Luena | ABC Maritime | 48000 | Malta | Tanker | fitter |
31.07.2008 |
05.10.2008 |
| Rio Gauya | ABC Maritime | 56693 | Malta | Tanker | fitter |
05.10.2008 |
31.01.2009 |
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Experience at sea: Since 1982 |
Knowledge Personal Computer (Yes / No): Yes | |||
| Medical Certificate | Issued: | Place: | Exp.date: | |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 12.12.2011 | |||