APPLICATION FORM
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APPLICATION FORM |
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| Name: Yevgeniy | Surname: Bulat | ||||||
| Date of birth: 13.11.1983 | Place of birth: Odessa | ||||||
| Permanent address: Kherson, Ukraine | |||||||
| Passport (OVIR): AH 838931 | Place of issue: Kherson | Date of issue: 03.12.2001 | Valid until: 03.12.2011 | ||||
| Seaman’s book: AB 276292 | Place of issue: Kherson | Date of issue: 20.12.2005 | Valid until: 20.12.2010 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: 2011 | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Bulat Maia | ||||||
| Supported children under age of 18 | 1. Platon Bulat | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Very good | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Kherson Marine Institute | Specialist of Navigation | . | 2006 | ||||
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Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 00742/2008/07 | Nikolaev |
18.06.2008 |
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| Endorsement STCW | 00742/2008/07 | Nikolaev |
18.06.2008 |
30.05.2013 |
| Personal Sea Survival (ÁÆÑ)(A-VI/1) | 105669/mps | Kherson |
30.05.2008 |
30.05.2013 |
| G.M.D.S.S. General Operator (A-IV/2) Certificate | 00463/2003/07 | Nikolaev |
30.07.2003 |
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| G.M.D.S.S. General Operator (A-IV/2) Endorsement | 00463/2003/07 | Nikolaev |
30.07.2003 |
30.05.2013 |
| Radar Observation and Plotting (A-II/1,2) | 0506/08KH | Kherson |
02.06.2008 |
02.06.2013 |
| Automatic Radar Plotting Aids (ARPA) (A-II/1,2) | 0506/08KH | Kherson |
02.06.2008 |
02.06.2013 |
| Carrying dangerous & hazardous cargo (B-V/4, B-V/5) | 11794/mps | Kherson |
30.05.2008 |
30.05.2013 |
| Advanced Fire Fighting (A-VI/3) | 13433/mps | Kherson |
30.05.2008 |
30.05.2013 |
| Proficiency in Survival Craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 14277/mps | Kherson |
30.05.2008 |
30.05.2013 |
| Ship's Medical Care (A-VI/4-2) | 1912/mps | Kherson |
30.05.2008 |
30.05.2013 |
| Dutch Seaman's Book | A 227017 | Netherlands |
14.07.2006 |
14.05.2008 |
| Dutch Endorsement | 00418/2005/11 | Netherlands |
14.05.2008 |
14.07.2016 |
Sea Service (during five last years):
|
Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Gastrikland | Tom worden |
5600 |
Isle of man |
MPC |
Ch. Off |
12.12.2005 |
08.04.2006 |
| Virginiaborg | Wagenborg |
9900 |
Dutch |
MPC |
Ch. Off |
02.07.2006 |
26.10.2006 |
| Maersk erimo | Maersk Shipmanagement |
8600 |
Dutch |
Cont |
Ch. Off |
11.01.2007 |
20.05.2007 |
| Endeavor | Jr Shipping |
9800 |
Dutch |
Cont |
Ch. Off |
17.08.2007 |
24.09.2007 |
| Electra | Jr Shipping |
9600 |
Dutch |
Cont |
Ch. Off |
19.11.2007 |
05.03.2008 |
| Elite | Jr Shipping |
13700 |
Dutch |
Cont |
Ch. Off |
15.03.2008 |
14.05.2008 |
| Taga Bay | Reederei Shipping |
13800 |
Liberia |
Cont |
Ch. Off |
05.08.2008 |
11.12.2008 |
| Experience at sea: Since 2001 | Knowledge Personal Computer: Yes | |||
| Medical Certificate: | ¹ | Issued: | Place: | Exp. date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: | |||