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APPLICATION FORM |
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| 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 | |||||
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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):
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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 |
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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 | |||