APPLICATION FORM
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APPLICATION FORM |
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| Name: Mykola | Surname: Alekseyev | |||||||
| Date of birth: 11.02.1951 | Place of birth: Zaporogye | |||||||
| Permanent address: Nikolaev, Ukraine | ||||||||
| Passport (OVIR): AC770781 | Place of issue: Nikolaev | Date of issue: 18.03.1997 | Valid until: 18.03.2007 | |||||
| Seaman’s book: AB125163 | Place of issue: Kherson | Date of issue: 19.11.1994 | Valid until: 18.03.2007 | |||||
| Citizenship: Ukrainian | Expiry date of U.S. visa: NO | |||||||
| Marital Status | Divorced | |||||||
| Next of kin: (name, pas. No) | ||||||||
| Supported children under age of 18 | ||||||||
| (name, surname, date of birth) | ||||||||
| Knowledge of English language | Satisfactory | |||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | |||||
| Kherson Maritime College | Engineer | 29.11.1975 | ||||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency(engineer) | 03577/2003/01 | Izmail |
17.12.2003 |
17.11.2008 |
| Endorsement STCW | 03577/2003/01 | Izmail |
17.12.2003 |
17.11.2008 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) | 4043/03KH | Kherson |
21.11.2003 |
21.11.2008 |
| Carrying dangerous & hazardous cargo (B-V/4, B-V/5) | 06066/03KH | Kherson |
20.11.2003 |
20.11.2008 |
| Advanced Fire Fighting (A-VI/3) | 1692/03KH | Kherson |
21.11.2003 |
21.11.2008 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 2144/03KH | Kherson |
21.11.2003 |
21.11.2008 |
| Medical First Aid (A-VI/4-1) | 1205/03KH | Kherson |
21.11.2003 |
21.11.2003 |
| Special course for navigators of tag-boats | 164/2004 | Nikolaev |
10.09.2004 |
10.09.2009 |
| Maintenance of Electrical and Electronic Engineering | 0335/03KH | Kherson |
17.11.2003 |
17.11.2008 |
| Certificate of competency(1-st class deck) | 00086/2004/07 | Nikolaev |
21.07.2004 |
21.07.2009 |
| Endorsement | 00086/2004/07 | Nikolaev |
21.07.2004 |
21.07.2009 |
| G.M.D.S.S. general operator (A-IV/1) Certificate | 109/2002 | Odessa |
01.03.2002 |
01.03.2007 |
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G.M.D.S.S. general operator (A-IV/2) Endorsement |
109/2002 | Odessa |
01.03.2002 |
01.03.2007 |
| Radar observation & plotting (A-II/1,2) | 1/2002 | Nikolaev |
18.01.2002 |
18.01.2007 |
| Ship's Medical Care (A-VI/4-2) | 7142KS | Kyiv |
16.07.2004 |
16.07.2009 |
Sea service (during five last years):
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Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| 1. M/v Kohanov | Delta pilot | 1020/1344 | Ukraine | Motor-vessel |
Chief-engineer |
15.07.2001 |
01.06.2004 |
| 2. Gaydomaka | Delta pilot | 5070/182 | Ukraine | Tag |
Chief-engineer |
02.06.2004 |
07.07.2006 |
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Automation (A1/A2) |
Main Eng. Maker/Model |
Engine Stroke |
Engine Total HP |
Aux. Engine Maker/Number |
Aux. Engine H.P. / KW |
Unmanned |
Without El.Eng. |
| 1. A1 |
Volvopenta/Tamd162C |
4 |
1020 |
Doits2003/3 |
108/80 |
yes |
yes |
| 2. A1 |
Catterpiller/3516 |
4 |
5070 |
Volvopenta74A |
312/450 |
yes |
yes |
| Experience at sea: Since 1976 | Knowledge Personal Computer (Yes / No): yes | |||
| Medical Certificate | ¹01533 | Issued: 03.07.2006 | Place: NIkolaev | Exp.date: 03.07.2007 |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: | |||