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APPLICATION FORM |
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| Name: Volodymyr | Surname: Gorodnycenko | ||||||
| Date of birth: 22.04.1975 | Place of birth: Odessa | ||||||
| Permanent address: Odessa, Ukraine | |||||||
| Passport (OVIR): AK 908216 | Place of issue: Odessa | Date of issue: 25.04.2006 | Valid until: 25.04.2016 | ||||
| Seaman’s book: AB 259025 | Place of issue: Odessa | Date of issue: 05.11.2002 | Valid until: 10.09.2010 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Gorodnychenko Irina | ||||||
| Supported children under age of 18 | 1. Anna Gorodnychenko, 27.11.1999 | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Good | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Odessa High Vocational School #26 | Cook | . | 05.06.1995 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
01077/2003/01 |
Izmail |
03.10.2003 |
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| Endorsement STCW |
01077/2003/01 |
Illichivsk |
04.09.2008 |
04.09.2013 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
107973B |
Odessa |
14.07.2008 |
14.07.2013 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
61448B |
Odessa |
17.01.2006 |
17.01.2011 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
| Spirit | V.Ships |
. |
Nasau |
Bulker |
Messman |
15.07.2004 |
12.01.2005 |
| Rosa M | Dopson |
. |
Malta |
Container |
Cook |
09.06.2006 |
08.11.2006 |
| Experience at sea: Since 2000 | Knowledge Personal Computer (Yes / No): | |||
| Medical Certificate | ¹ | Issued: | Place: | Exp.date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: | |||
Ready to work from: any time