APPLICATION FORM
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APPLICATION FORM |
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| Name: Andriy | Surname: Mozgunov | ||||||
| Date of birth: 28.09.1967 | Place of birth: Kazakhstan | ||||||
| Permanent address: Odessa, Ukraine | |||||||
| Passport (OVIR): AC 804483 | Place of issue: Odessa | Date of issue: 15.04.1997 | Valid until: 15.04.2017 | ||||
| Seaman’s book: AB 286317 | Place of issue: Illychevsk | Date of issue: 29.12.2003 | Valid until: 29.12.2008 | ||||
| Citizenship: Ukraine | Expiry date of U.S. visa: 2011 | ||||||
| Marital Status | Married | ||||||
| Next of kin: (name, pas. No) | wife - Tarasova Elena | ||||||
| Supported children under age of 18 | 1. Mozgunov Daniil, 08.05.2001 | ||||||
| (name, surname, date of birth) | . | ||||||
| Knowledge of English language | Satisfactory | ||||||
| Education: | Qualification: | No Diploma: | Date of Issue: | ||||
| Kherson Marine College | Navigator | . | 2007 | ||||
|
Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 00966/2007/07 | Nikolaev |
16.07.2007 |
--- |
| Endorsement STCW | 00966/2007/07 | Nikolaev |
16.07.2007 |
16.07.2012 |
| Personal Sea Survival (ÁÆÑ)(A-VI/1) | 1407/2007 | Odessa |
13.07.2007 |
13.07.2012 |
| G.M.D.S.S. General Operator (A-IV/2) Certificate | 00436/2007/03 | Illychevsk |
04.07.2007 |
04.07.2012 |
| G.M.D.S.S. General Operator (A-IV/2) Endorsement | 00436/2007/03 | Illychevsk |
04.07.2007 |
04.07.2012 |
| Radar Observation and Plotting (A-II/1,2) | 3798 M/T | Odessa |
25.05.2007 |
25.05.2012 |
| Automatic Radar Plotting Aids (ARPA) (A-II/1,2) | 3798 M/T | Odessa |
25.05.2007 |
25.05.2012 |
| Carrying dangerous & hazardous cargo (B-V/4, B-V/5) | DG0113/2007 | Odessa |
04.07.2007 |
04.07.2012 |
| Advanced Fire Fighting (A-VI/3) | 2/89/07 | Odessa |
09.07.2007 |
09.07.2012 |
| Proficiency in Survival Craft, Rescue Boats & Fast Rescue Boats (A-VI/2) | 1223/2007 | Odessa |
12.07.2007 |
12.07.2012 |
| Medical First Aid (A-VI/4-1) | 05061 M/T | Odessa |
18.05.2007 |
18.05.2012 |
| Panama Endorsement | 00096/2007/07 | Panama |
28.04.2008 |
12.06.2012 |
| Panama G.M.D.S.S. | 00436/2007/03 | Panama |
28.04.2008 |
22.05.2012 |
| Singapore Endorsement | 00966/2007/07 | Singapore |
28.04.2008 |
22.05.2012 |
| Singapore G.M.D.S.S. | 00436/2007/03 | Panama |
28.04.2008 |
22.05.2012 |
Sea Service (during five last years):
|
Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Venus | UMS |
18483 |
N.Antilles |
Container |
AB |
26.11.2004 |
23.08.2005 |
| Safmarine Amazon | UMS |
25049 |
Germany |
Container |
AB |
10.09.2005 |
17.12.2005 |
| Maersk Hong Kong | UMS |
25049 |
N.Antilles |
Container |
AB |
20.01.2006 |
05.08.2006 |
| CMA SGM Cotres | UMS |
25049 |
Germany |
Container |
AB |
06.11.2006 |
19.04.2007 |
| Maersk Valparaiso | UMS |
25049 |
Marshall isl. |
Container |
AB |
19.07.2007 |
16.01.2008 |
| Ocean Chie | Singh Marine |
50000 |
Panama |
Bulker |
3-rd Off |
17.03.2008 |
20.09.2008 |
| Global Glory | Singh Marine |
50000 |
Panma |
Bulker |
3-rd Off |
15.12.2008 |
22.06.2009 |
| Experience at sea: Since 2003 | Knowledge Personal Computer: Yes | |||
| Medical Certificate: | ¹ | Issued: | Place: | Exp. date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 2011 | |||