APPLICATION FORM
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APPLICATION FORM |
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| Name: Vitaliy | Surname: Khutkovskiy | ||||||
| Date of birth: 30.10.1983 | Place of birth: Lvov, Ukraine | ||||||
| Permanent address: Kherson, Ukraine | |||||||
| Passport (OVIR): AH 842048 | Place of issue: Kherson | Date of issue: 04.02.2002 | Valid until: 04.02.2012 | ||||
| Seaman’s book: AB 358591 | Place of issue: Nikolaev | Date of issue: 30.07.2008 | Valid until: 29.07.2013 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: NO | ||||||
| Marital Status | Married | ||||||
| Next of kin: | wife - Khutkovskaya Tetyana | ||||||
| Supported children under age of 18 | Khutkovskiy Ivan - 28.05.2007 | ||||||
| (name, surname, date of birth) | |||||||
| Knowledge of English language | Very Good | ||||||
| Education: | Qualification: | Date of Issue: | |||||
| Kherson Maritime College | Bachelar Navigator | 05.06.2004 | |||||
| Kherson Maritime Institute | Specialist Navigator | 15.05.2008 | |||||
|
Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 01048/2003/07 | Nikolaev |
21.07.2003 |
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| Endorsement STCW | 01048/2003/07 | Nikolaev |
31.07.2008 |
16.07.2013 |
| Personal Sea Survival (ÁÆÑ) (A-VI/1) | 06894/2008/42/01 | Nikolaev |
16.07.2008 |
16.07.2013 |
| G.M.D.S.S. General Operator (A-IV/2) Certificate | 00435/2003/07 | Nikolaev |
15.07.2003 |
--- |
| G.M.D.S.S. General Operator (A-IV/2) Endorsement | 00435/2003/07 | Nikolaev |
30.07.2008 |
29.07.2013 |
| Radar Observation and Plotting (A-II/1,2) | 00446/2008/42/30 | Nikolaev |
16.07.2008 |
16.07.2013 |
| Automatic Radar Plotting Aids (ARPA) (A-II/1,2) | 00446/2008/42/30 | Nikolaev |
16.07.2008 |
16.07.2013 |
| Carrying dangerous & hazardous cargo (B-V/4, B-V/5) | 03718/2008/42/20 | Nikolaev |
16.07.2008 |
16.07.2013 |
| Advanced Fire Fighting (A-VI/3) | 03159/2008/42/04 | Nikolaev |
16.07.2008 |
16.07.2013 |
| Proficiency in Survival Craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 05512/2008/42/02 | Nikolaev |
16.07.2008 |
16.07.2013 |
| Medical First Aid (A-VI/4-1) | 02068/2008/42/05 | Nikolaev |
16.07.2008 |
16.07.2013 |
| Proficiency in Fast Rescue Boat | 10278/MPS | Kherson |
19.09.2008 |
19.09.2013 |
| DP Induction Course | 0015/2010 | Odessa |
19.02.2010 |
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Tanker Certificates |
. |
. |
. |
. |
| Chemical Tanker (Advanced & Familiarization, A-V/1, p.2-7) | 01137/2008/42/10 | Nikolaev |
16.07.2008 |
16.07.2013 |
| LPG carrier (Advanced & Familiarization, A-V/1, p.2-7) | 01137/2008/42/10 | Nikolaev |
16.07.2008 |
16.07.2013 |
| Oil Tanker (Advanced & Familiarization, A-V/1, p.2-7) | 01137/2008/42/10 | Nikolaev |
16.07.2008 |
16.07.2013 |
Sea Service (during five last years):
|
Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Amalthia | Target Marine S.A. Greece |
17050 |
Bahamas |
reefer |
AB |
18.08.2004 |
05.02.2005 |
| Antiope | Target Marine S.A. Greece |
17050 |
Bahamas |
reefer |
AB |
18.10.2005 |
24.04.2006 |
| Nancy | Swedush Shipmanagement |
13700 |
Panama |
bulker |
2-nd Off |
26.02.2007 |
04.10.2007 |
| Prem Veena | Vector Shipping Management |
84019 |
Singapore |
bulker |
2-nd Off |
22.11.2007 |
08.03.2008 |
| Zamil-17 | Zamil Offshore Services Co |
1547 |
Bahrain |
AHTS |
2-nd Off |
27.04.2009 |
04.08.2009 |
| Zamil-60 | Zamil Offshore Services Co |
1547 |
Bahrain |
AHTS |
2-nd Off |
15.10.2009 |
27.01.2010 |
| Experience at sea: Since 2002 | Knowledge Personal Computer: Yes | |||
| Medical Certificate: | ¹ 03226 | Issued: 27.08.2009 | Place: Kherson | Exp. date: 27.08.2010 |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 11.04.2012 | |||