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APPLICATION FORM

 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

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

 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

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