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APPLICATION FORM

 Name: Andrii  Surname: Skotnytskyi
 Date of birth: 23.07.1977  Place of birth: Odessa reg.
 Permanent address: Nikolaev, Ukraine
 Passport (OVIR):  EC 729181  Place of issue: Nikolaev  Date of issue: 13.09.2006  Valid until: 13.09.2016
 Seaman’s book: AB 302253  Place of issue: Ilyichevsk  Date of issue: 10.01.2007  Valid until: 10.01.2012
 Citizenship: Ukraine  Expiry date of U.S. visa: NO
 Marital Status  Married
 Next of kin: (name, pas. No)  .
 Supported children under age of 18  1. Skotnytskyi Vlad. 26.10.1998
 (name, surname, date of birth)  .
 Knowledge of English language  Poor
 Education:  Qualification:  No Diploma:  Date of Issue:
 Odessa Vocational School #14   motorman  001249  23.06.1995

 Certificates of STCW 78/95

 No.

 Place

 Date of issue

 Expiry date

 Certificate of competency  00690/2006/03  Ilyichevsk

02.10.2006

---

 Endorsement STCW  00690/2006/03  Ilyichevsk

07.12.2007

30.08.2011

 Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1)  02013/2006/42/01  Nikolaev

30.08.2006

30.08.2011

 Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2)  01251/2006/42/02  Nikolaev

30.08.2006

30.08.2011

 Tanker Certificates

.

.

.

.

 Chemical Tanker (Advanced and Familiarization, A-V/1, p.2-7)  00665/2007/42/10  Nikolaev

14.11.2007

14.11.2012

 LPG carrier (Advanced and Familiarization, A-V/1, p.2-7)  00665/2007/42/10  Nikolaev

14.11.2007

14.11.2012

 Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7)  00665/2007/42/10  Nikolaev

14.11.2007

14.11.2012

Sea service (during five last years):

Name of vessel

Company

DWT

Flag

Type

Position

From

To

 Trubezh  Clifton bay

17270

Belize

Gen cargo

oiler

09.02.2007

08.09.2007

 Experience at sea:

 Knowledge Personal Computer (Yes / No):
 Medical Certificate  Issued:  Place:  Exp.date:
 Vaccination for cholera valid until:  Vaccination for yellow fever

Ready to work from:  any time

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