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APPLICATION FORM |
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| Name: Mykhaylo | Surname: Ul'yanov | ||||||
| Date of birth: 10.02.1988 | Place of birth: Kherson | ||||||
| Permanent address: Kherson, Ukraine | |||||||
| Passport (OVIR): EE 058164 | Place of issue: Kherson | Date of issue: 23.05.2008 | Valid until: 23.05.2018 | ||||
| Seaman’s book: AB 362889 | Place of issue: Kherson | Date of issue: 23.10.2007 | Valid until: 23.10.2012 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Single | ||||||
| Next of kin: (name, pas. No) | Ul'yanov Il'ya | ||||||
| Supported children under age of 18 | |||||||
| (name, surname, date of birth) | |||||||
| Knowledge of English language | Satisfactory | ||||||
| Education: | Qualification: | Date of Issue: | |||||
| Kherson Maritime Training Centre | Electrician | 13.02.2008 | |||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
00011/2008/11 |
Kherson |
13.02.2008 |
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| Endorsement STCW |
00011/2008/11 |
Kherson |
13.02.2008 |
21.09.2012 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
11725/07 KH |
Kherson |
21.09.2007 |
21.09.2012 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
8023/07 KH |
Kherson |
21.09.2007 |
21.09.2012 |
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Tanker Certificates |
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| Chemical Tanker (Advanced and Familiarization, A-V/1, p.2-7) |
0776/07 KH |
Kherson |
14.12.2007 |
14.12.2012 |
| LPG carrier (Advanced and Familiarization, A-V/1, p.2-7) |
0776/07 KH |
Kherson |
14.12.2007 |
14.12.2012 |
| Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7) |
0776/07 KH |
Kherson |
14.12.2007 |
14.12.2012 |
Sea service (during five last years):
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Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| Baltic Strait |
Aquaship Ltd |
12545 |
Panama |
Reefer |
Electrician |
02.10.2008 |
02.05.2009 |
| Experience at sea: Since 2008 | Knowledge Personal Computer (Yes / No): Yes | |||
| Medical Certificate | ¹ | Issued: | Place: | Exp.date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 27.11.2017 | |||