APPLICATION FORM
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APPLICATION FORM |
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| Name: Mikhail | Surname: Fomin | ||||||
| Date of birth: 10.12.1967 | Place of birth: Stavropol reg. | ||||||
| Permanent address: Kazan, Tatarstan | |||||||
| Passport (OVIR): 5649718 | Place of issue: Kazan | Date of issue: 22.02.2008 | Valid until: 22.02.2013 | ||||
| Seaman’s book: ÌÔ 0276012 | Place of issue: N.Novgorod | Date of issue: 04.05.2009 | Valid until: 31.12.2013 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Nataliya Fomina, 92 05 923058 | ||||||
| Supported children under age of 18 | Fomin Ilya, 1993 | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Good | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Kazan River College | Tech. Navigation | . | 01.04.1987 | ||||
| Samara River College | Sea Navigation | . | 28.04.2000 | ||||
|
Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 20302011965 | Astrakhan |
30.05.2007 |
--- |
| Endorsement STCW | 20302011965 | Astrakhan |
30.05.2007 |
20.05.2011 |
| Personal Sea Survival (ÁÆÑ)(A-VI/1) | 093209 | Astrakhan |
20.05.2006 |
20.05.2011 |
| G.M.D.S.S. General Operator (A-IV/2) Certificate | 0036429 | Taganrog |
18.04.2002 |
--- |
| G.M.D.S.S. General Operator (A-IV/2) Endorsement | 0036429 | Taganrog |
18.04.2002 |
28.03.2012 |
| Radar Observation and Plotting (A-II/1,2) | 0080242 | Astrakhan |
19.05.2006 |
19.05.2011 |
| Automatic Radar Plotting Aids (ARPA) (A-II/1,2) | 0080242 | Astrakhan |
19.05.2006 |
19.05.2011 |
| Advanced Fire Fighting (A-VI/3) | 051338 | Rostov |
25.01.2007 |
25.01.2012 |
| Proficiency in Survival Craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 100242 | Rostov |
23.01.2007 |
23.01.2012 |
| Medical First Aid (A-VI/4-1) | 055602 | Rostov |
24.01.2007 |
24.01.2012 |
Sea Service (during five last years):
|
Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Novosibirsk | Ortsintes |
4300 |
Russia |
Tanker |
Ch. Off |
16.05.2004 |
24.11.2004 |
| Novosibirsk | Ortsintes |
4300 |
Russia |
Tanker |
Ch. Off |
02.05.2005 |
28.12.2005 |
| Pushkino | Yenisey River Ship. Co |
2180 |
Russia |
Gen cargo |
Ch. Off |
18.07.2006 |
27.10.2006 |
| Dmitrov | Yenisey River Ship. Co |
2180 |
Russia |
Gen cargo |
Ch. Off |
07.11.2006 |
02.05.2007 |
| Samur 11 | Albros |
2755 |
Russia |
Gen cargo |
Ch. Off |
22.06.2007 |
13.10.2007 |
| Brin-Navolok | Belfreight |
3180 |
Russia |
Gen cargo |
Ch. Off |
12.03.2008 |
03.06.2008 |
| Aras 9 | Transoptimal |
2350 |
Siere Leone |
Gen cargo |
Ch. Off |
03.07.2008 |
09.09.2008 |
| Leiria | Naveiro |
2652 |
Portugal |
Gen cargo |
Ch. Off |
03.12.2008 |
09.03.2009 |
| Experience at sea: Since 2000 | Knowledge Personal Computer: Yes | |||
| Medical Certificate: | ¹ 1504 | Issued: 03.03.2009 | Place: Rostov-on-Don | Exp. date: 03.03.2010 |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: | |||