APPLICATION FORM
|
|
APPLICATION FORM
|
|
| Name: | Tetyana | ||||
| Surname: | Kosakovska | ||||
|
Date of Birth: |
02.11.1966 | ||||
| Place of Birth: | Moldova, Kishinev | ||||
| Permanent address: | 60/1, Vilyemsa Str., ap.13, Odessa, 65015, Ukraine | ||||
| Citizenship: | Ukraine | ||||
| Passport No.: | AC 801572 | ||||
| Date of issue: | 19.02.1997 | ||||
| Place of issue: | Odessa, Ukraine | ||||
| Valid untill: | 19.02.2007 | ||||
| Seaman's Book No.: | AB 076786 | ||||
| Date of issue: | 31.07.2001 | ||||
| Place of issue: | Port Ilyichevsk, Ukraine | ||||
| Valid untill: | 31.07.2006 | ||||
| Expiry date of U.S. visa: | - | ||||
| vaccination for cholera valid untill: | - | ||||
| vaccination for yellow fever valid untill: | 30.09.2007 | ||||
| Date of last medical certificate: | 20.01.1999 | ||||
| Marital status: | Married: X | Single: | Divorced: | Widower: | |
| Next of kin: (name, pas. No) | husband - Gordienko Nicolay pas. AC 341696 | ||||
| Supported children under age of 18 | 1. son - Gordienko Phillip 22. 07. 1993. | ||||
| (name, surname, date of birth) | - | ||||
| Knowledge of English language: | Very good: | Good: X | Satisfactory: | Fair | Poor: |
Licences, grades, certificates:
|
Licence held/grade, certificate |
No. |
Authority |
Country |
Date of issue |
Expiry date |
| Ro-Ro pass. ships |
0522/R-99 |
- |
Ukraine |
31.08.99 |
31.08.04 |
| Fire fighting |
43857 |
- |
Ukraine |
27.08.99 |
27.08.04 |
| Cert. competency |
394 |
- |
Ukraine |
26.08.99 |
26.08.04 |
| Diploma: High Vocational school ¹26 |
438582 |
- |
Ukraine |
15.07.86 |
- |
Sea service (during five last years):
|
Name of vessel |
Company |
HP/DWT |
Flag |
Type |
Position |
From |
To |
| "Shota Rustaveli" | Blasco |
750 pass |
Ukraine |
pass |
waitress |
1986 |
1996 |
| "Switzarland" | Monrovia |
440 pass |
Monr. |
pass. |
stewardess |
22.02.1997 |
29.09.1997 |
| "Switzarland" | Dream line cruises |
440 pass |
Monr. |
pass. |
stewardess |
09.10.1997 |
17.06.1998 |
| "Switzarland" | Dream line cruises |
440 pass |
Monr. |
pass. |
stewardess |
29.01.1999 |
15.08.1999 |
| "Switzarland" | Dream line cruises |
440 pass |
Monr. |
pass. |
stewardess |
07.10.1999 |
01.06.2000 |
| "Minerva" | V.Ships Leisure Inc |
440 pass |
Monaco |
pass. |
stewardess |
15.02.2003 |
20.10.2003 |
Ready to work from: 11.2004