APPLICATION FORM
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APPLICATION FORM |
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| Name: Sergiy | Surname: Beregovoy | ||||||
| Date of birth: 29.05.1946 | Place of birth: Kiev reg. | ||||||
| Permanent address: Odessa, Ukraine | |||||||
| Passport (OVIR): PO 656296 | Place of issue: Odessa | Date of issue: 11.06.2007 | Valid until: 11.06.2017 | ||||
| Seaman’s book: AB 436700 | Place of issue: Odessa | Date of issue: 28.04.2010 | Valid until: 18.03.2015 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Beregova Iryna, PO 656295 | ||||||
| Supported children under age of 18 | |||||||
| (name, surname, date of birth) | |||||||
| Knowledge of English language | Good | ||||||
| Education: | Qualification: | Date of Issue: | |||||
| Batumi Marine College | Deep Sea Navigator | 28.02.1966 | |||||
| Odessa National Maritime University | Maritime management | 23.12.1975 | |||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 0001/2002/08 | Odessa |
29.04.2010 |
29.04.2015 |
| Endorsement STCW | 0001/2002/08 | Odessa |
21.06.2007 |
18.01.2010 |
| Personal Sea Survival (ÁÆÑ)(A-VI/1) | 92480/07 | Odessa |
13.06.2007 |
13.06.2012 |
| G.M.D.S.S. General Operator (A-IV/2) Certificate | 0002/2002/08 | Odessa |
29.04.2010 |
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| G.M.D.S.S. General Operator (A-IV/2) Endorsement | 0002/2002/08 | Odessa |
29.04.2010 |
29.04.2015 |
| Radar Observation and Plotting (A-II/1,2) | 0147/2010 | Odessa |
02.04.2010 |
02.04.2015 |
| Automatic Radar Plotting Aids (ARPA) (A-II/1,2) | 0147/2010 | Odessa |
02.04.2010 |
02.04.2015 |
| Carrying dangerous & hazardous cargo (B-V/4, B-V/5) | 0323 U | Izmail |
13.06.2007 |
13.06.2012 |
| Advanced Fire Fighting (A-VI/3) | 46969/07 | Odessa |
13.06.2007 |
13.06.2012 |
| Proficiency in Survival Craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 52601 | Odessa |
13.06.2007 |
13.06.2012 |
| Ship's Medical Care (A-VI/4-2) | 0177/2010 | Odessa |
02.04.2010 |
02.04.2015 |
| Refresher and updating courses (II/1) | 0365/07 | Izmail |
13.06.2007 |
13.06.2012 |
| Ship Security Officer | 1259/2008 | Odessa |
05.12.2008 |
05.12.2013 |
| Ship Safety Officer | 0381/2003 | Odessa |
11.12.2003 |
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Sea Service (during five last years):
|
Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Persepolis | Bulk carrier shipping |
17188 |
Panama |
Multipurp |
Master |
11.04.2005 |
24.12.2005 |
| St. Anna | Ocean Agencies |
52640 |
Liberia |
Bulk carrier |
Master |
20.09.2006 |
08.05.2007 |
| Alma 1 | Priamos Marine |
25000 |
Panama |
Bulk carrier |
Master |
24.06.2008 |
14.10.2008 |
| L.S. Aizenshtat | Kaalbye Shipping |
8717(400TEU) |
St.Vincent |
Container |
Master |
24.05.2009 |
07.11.2009 |
| Experience at sea: Since 1961 | Knowledge Personal Computer: Yes | |||
| Medical Certificate: | ¹ 00801 | Issued: 22.05.2009 | Place: Odessa | Exp. date: 22.05.2010 |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 01.08.2013 | |||