APPLICATION FORM

 Name: Andrii  Surname: Trybushnyi
 Date of birth: 18.10.1987  Place of birth: Kherson
 Permanent address: Kherson, Ukraine
 Passport (OVIR): EE 836126  Place of issue: Kherson  Date of issue: 30.12.2008  Valid until: 30.12.2018
 Seaman’s book: AB 418156  Place of issue: Kherson  Date of issue: 24.12.2008  Valid until: 24.12.2013
 Citizenship: Ukraine  Expiry date of U.S. visa: NO
 Marital Status  Single
 Next of kin: (name, pas. No)  mother - Tribushnaya Svetlana
 Supported children under age of 18  
 (name, surname, date of birth)  
 Knowledge of English language  Satisfactory
 Education:  Qualification:  Date of Issue:
 Kherson Maritime Training Center   motorman  29.12.2008

 Certificates of STCW 78/95

 No.

 Place

 Date of issue

 Expiry date

 Certificate of competency  00017/2009/11  Kherson

06.02.2009

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 Endorsement STCW  00017/2009/11  Kherson

06.02.2009

06.02.2013

 Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1)  13791/08 KH  Kherson

26.09.2008

26.09.2013

 Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2)  9739/08 KH  Kherson

26.09.2008

26.09.2013

 Passenger ships other than Ro-Ro (A-V/3)  0369/08 KH  Kherson

05.12.2008

05.12.2013

Sea service (during five last years):

Name of vessel

Company

DWT

Flag

Type

Position

From

To

 BT-0645  Deltaservices    Ukraine

 Tug

cadet

17.10.2008

17.12.2008

 Uros   Greece European Co  2786  Georgia  Gen cargo

wiper

17.05.2009

19.10.2009

 Experience at sea: Since 2008

 Knowledge Personal Computer (Yes / No): Yes 
 Medical Certificate # 03673  Issued: 25.11.2009  Place: Kherson  Exp.date: 25.11.2010
 Vaccination for cholera valid until:  Vaccination for yellow fever valid until: 19.02.2019