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APPLICATION FORM |
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| Name: Volodymyr | Surname: Kozlovsky | ||||||
| Date of birth: 07.12.1979 | Place of birth: Odessa Reg., Ukraine | ||||||
| Permanent address: Odessa Reg., Ukraine | |||||||
| Passport (OVIR): AX 964159 | Place of issue: Odessa | Date of issue: 13.11.2003 | Valid until: 13.11.2013 | ||||
| Seaman’s book: AB 328892 | Place of issue: Odessa | Date of issue: 24.09.2004 | Valid until: 24.09.2009 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Single | ||||||
| Next of kin: (name) | mother - Kozlovskaya Zhanna | ||||||
| Supported children under age of 18 | -- | ||||||
| (name, surname, date of birth) | -- | ||||||
| Knowledge of English language | Satisfactory | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Profeshional Technical College # 37 | Cook | CK # 11762223 | 30.06.2002 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency |
00196/2005/08 |
Odessa |
17.03.2005 |
28.01.2009 |
| Endorsement STCW |
00196/2005/08 |
Odessa |
17.03.2005 |
28.01.2009 |
| Personal Sea Survival techniques, fire prevention and fire fighting (A-VI/1) |
75131/2004 |
Odessa |
28.07.2004 |
28.07.2008 |
| Proficiency in Survival craft, Rescue Boats & Fast Rescue Boats (A-VI/2) |
081 ILL |
Illichivsk |
01.03.2005 |
01.03.2010 |
Sea service (during five last years):
|
Name of vessel |
COMPANY |
DWT |
Flag |
Type |
Position |
From |
To |
|
DRUZHBA |
ONMA |
1260 |
UKR |
sailing |
cook |
01.07.2003 |
26.04.2005 |
| Nevchcivan | Pelikan Shipping |
1900 |
Panama |
coaster |
AB |
10.09.2005 |
18.02.2006 |
|
Kairos |
Split Ship Menagament |
2900 |
St. Vinsent |
bulker |
cook |
23.04.2006 |
27.10.2006 |
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Experience at sea: Since 2002 |
Knowledge Personal Computer (Yes / No): Yes | |||
| Medical Certificate | ¹ | Issued: | Place: | Exp.date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: | |||
Ready to work from: any time