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APPLICATION FORM |
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| 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 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 00690/2006/03 | Ilyichevsk |
02.10.2006 |
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| 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 |
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Tanker Certificates |
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. |
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| 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):
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Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Trubezh | Clifton bay |
17270 |
Belize |
Gen cargo |
oiler |
09.02.2007 |
08.09.2007 |
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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