APPLICATION FORM
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APPLICATION FORM |
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| Name: Maxim | Surname: Antonov | ||||||
| Date of birth: 27.06.1981 | Place of birth: Kerch | ||||||
| Permanent address: Kerch, Ukraine | |||||||
| Passport (OVIR): AC 704977 | Place of issue: Kerch | Date of issue: 17.01.2001 | Valid until: 17.01.2011 | ||||
| Seaman’s book: AB 045107 | Place of issue: Sevastopol | Date of issue: 24.04.2003 | Valid until: 24.04.2013 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: 02.08.2011 | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Antonova Olena | ||||||
| Supported children under age of 18 | 1. Aksinya Antonova, 15.09.2009 | ||||||
| (name, surname, date of birth) | |||||||
| Knowledge of English language | Good | ||||||
| Education: | Qualification: | Date of Issue: | |||||
| Kerch Marine Academy | Engineer | 30.06.2003 | |||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 00156/2003/04 | Kerch |
28.07.2003 |
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| Endorsement STCW | 00156/2003/04 | Kerch |
14.05.2008 |
28.02.2013 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) | 20090/MPS | Kerch |
29.02.2008 |
28.02.2013 |
| Advanced Fire Fighting (A-VI/3) | 07857/MPS | Kerch |
29.02.2008 |
28.02.2013 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 12919/MPS | Kerch |
29.02.2008 |
29.02.2013 |
| Medical First Aid (A-VI/4-1) | 05843/MPS | Kerch |
29.02.2008 |
29.02.2013 |
| Endorsement the republic of Liberia | 823138 | USA |
04.06.2008 |
28.02.2013 |
| Seamen's book the republic of Liberia | 0752427 | USA |
22.08.2006 |
22.08.2011 |
Sea service (during five last years):
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Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| 1. Hyundai National | Zodiac | 80551 | Great Britain | Container |
4-th Eng |
09.09.2005 |
09.01.2006 |
| 2. OOCL France | E.R. Schiffahrt | 67591 | Liberia | Container |
4-th Eng |
23.08.2006 |
01.02.2007 |
| 3. OOCL France | E.R. Schiffahrt | 67591 | Liberia | Container |
4-th Eng |
19.09.2007 |
31.01.2008 |
| 4. OOCL Malaysia | E.R. Schiffahrt | 67591 | Liberia | Container |
3-rd Eng |
07.07.2008 |
11.11.2008 |
| 5. CMA CGM Yantian | E.R. Schiffahrt | 40721 | Liberia | Container |
3-rd Eng |
04.03.2009 |
04.07.2009 |
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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 |
Man-B&W/12k98mc |
2 |
89640 |
Man B&W/4 |
/3000 |
Yes |
No |
| 2. A1 |
MAN-B&W/12k90mc |
2 |
74640 |
MAN B&W/3 |
/3000 |
Yes |
No |
| 3. A1 |
Man-B&W/12k90mc |
2 |
74640 |
Man B&W/3 |
/3000 |
Yes |
No |
| 4. A1 |
Man-B&W/12k90mc |
2 |
74640 |
Man B&W/3 |
/3000 |
Yes |
No |
| 5. A1 |
Man B&W/8k70mc |
2 |
49610 |
Daihatsu/3 |
/1800 |
Yes |
No |
| Experience at sea: Since 2003 | Knowledge Personal Computer (Yes / No): YES | |||
| Medical Certificate | ¹ | Issued: 21.10.2009 | Place: Ukraine | Exp.date: 21.10.2010 |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 18.04.2013 | |||