APPLICATION FORM
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APPLICATION FORM |
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| Name: Mykola | Surname: Bezsmertny | ||||||
| Date of birth: 11.11.1950 | Place of birth: Novokuznersk, Russia | ||||||
| Permanent address: Odessa, Ukraine | |||||||
| Passport (OVIR): EC 688127 | Place of issue: Odessa | Date of issue: 15.08.2006 | Valid until: 15.08.2016 | ||||
| Seaman’s book: AB 299881 | Place of issue: Ilyichevsk | Date of issue: 31.07.2006 | Valid until: 31.07.2011 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Zima Valentyna | ||||||
| Supported children under age of 18 | |||||||
| (name, surname, date of birth) | |||||||
| Knowledge of English language | Very good | ||||||
| Education: | Qualification: | Date of Issue: | |||||
| Odessa State Marine Academy | Engineer-Navigator | 1980 | |||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 01415/2003/08 | Odessa |
29.04.2003 |
--- |
| Endorsement STCW | 01415/2003/08 | Nikolaev |
30.05.2007 |
12.07.2011 |
| Personal Sea Survival (ÁÆÑ)(A-VI/1) | 01761/2006/42/01 | Nikolaev |
12.07.2006 |
12.07.2011 |
| G.M.D.S.S. General Operator (A-IV/2) Certificate | 00471/2003/08 | Odessa |
21.03.2003 |
--- |
| G.M.D.S.S. General Operator (A-IV/2) Endorsement | 00471/2003/08 | Nikolaev |
26.07.2006 |
26.07.2011 |
| Radar Observation and Plotting (A-II/1,2) | 00155/2006/42/31 | Nikolaev |
12.07.2006 |
12.07.2011 |
| Automatic Radar Plotting Aids (ARPA) (A-II/1,2) | 00155/2006/42/31 | Nikolaev |
12.07.2006 |
12.07.2011 |
| Carrying dangerous & hazardous cargo (B-V/4, B-V/5) | 00633/2006/42/20 | Nikolaev |
12.07.2006 |
12.07.2011 |
| Advanced Fire Fighting (A-VI/3) | 00538/2006/42/04 | Nikolaev |
12.07.2006 |
12.07.2011 |
| Proficiency in Survival Craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 01041/2006/42/01 | Nikolaev |
12.07.2006 |
12.07.2011 |
| Ship's Medical Care (A-VI/4-2) | 00150/2006/42/06 | Nikolaev |
12.07.2006 |
12.07.2011 |
| Ship Handling Arrangements | 00102/2006/42/60 | Nikolaev |
12.07.2006 |
12.07.2011 |
| Ship Security Officer (ISPS) A/2.1.6,A/12.1,A/12.2,B/8,B/9,B/13 | 2186/2009 | Odessa |
23.10.2009 |
23.10.2014 |
| Panama Seaman's book | 11GO407393 | Panama |
16.11.2006 |
12.07.2011 |
| Panama Endorsement | 11GO407393 | Panama |
16.11.2006 |
12.07.2011 |
| Refresher and updating courses (II/1) | ÑÏÊ 362582 | Nikolaev |
20.07.2006 |
20.07.2011 |
| Ro-Ro Passenger ships (A-V/2) | 0006/2006/42/08 | Nikolaev |
12.07.2006 |
12.07.2011 |
| Passenger ships other than Ro-Ro (A-V/3) | 00056/2006/42/09 | Nikolaev |
12.07.2006 |
12.07.2011 |
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Tanker Certificates: |
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| Chemical Tanker (Advanced and Familiarization, A-V/1, p.2-7) | LZ 00834B | Odessa |
17.05.2007 |
17.05.2012 |
| Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7) | 00079/2006/42/11 | Odessa |
12.07.2006 |
12.07.2011 |
| Crude oil washing | LZ 03861B | Odessa |
17.05.2007 |
17.05.2012 |
| Inert gas system | LZ01657B | Odessa |
17.05.2007 |
17.05.2012 |
Sea Service (during five last years):
|
Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Omar III | China |
18455 |
Panama |
Pass |
St.Capt |
14.05.2003 |
09.07.2006 |
| Efstathia M. | Refill Shipmanagenemt |
3500 |
Panama |
Ch. Tanker |
Master |
18.09.2006 |
31.05.2007 |
| Efstathia M. | Refill Shipmanagement |
3500 |
Panama |
Ch. Tanker |
Master |
01.08.2007 |
02.12.2007 |
| Efstathia M. | Refill Shipmanagement |
3500 |
Panama |
Ch. Tanker |
Master |
02.02.2008 |
01.07.2008 |
| Experience at sea: Since 1974 | Knowledge Personal Computer: Yes | |||
| Medical Certificate: | ¹ | Issued: | Place: | Exp. date: |
| Vaccinationfor cholera valid until: | Vaccination for yellow fever valid until: | |||