APPLICATION FORM
|
|
APPLICATION FORM |
|
| Name: Andriy | Surname: Pelikhov | Father’s name: Oleg | |||||||
| Date of birth: 29.05.1970 | Place of birth: Batumi, Adjar | Personal Code: | |||||||
| Permanent address: Mariupol, Ukraine | |||||||||
| Passport (OVIR): KC 622866 | Place of issue: Mariupol | Date of issue: 18.03.1999 | Valid until: 18.03.2009 | ||||||
| Seaman’s book: AB 144162 | Place of issue: Mariupol | Date of issue: 01.10.2001 | Valid until: 14.06.2005 | ||||||
| Citizenship: Ukraine | Expiry date of U.S. visa: 18.05.2009 | ||||||||
| Marital Status | Married | ||||||||
| Next of kin: (name, pas. No) | wife - Pelichova | ||||||||
| Supported children under age of 18 | son - Pelikhov Nikita | ||||||||
| (name, surname, date of birth) | - | ||||||||
| Knowledge of English language | Good | ||||||||
|
Certificates of STCW 78/95 |
No. |
Place |
Date of issue |
Expiry date |
| Certificate of competency | 00315/2003/06 | Mariupol | 13.03.2003 |
25.04.2005 |
| Endorsement STCW | 00315/2003/06 | Mariupol | 29.10.2003 |
25.04.2005 |
| Basic Safety Training STCW 78/95 | 00315/2003/06 | Mariupol | 07.10.2003 |
07.10.2008 |
| G.M.D.S.S. General Operator (A-IV/2) Certificate | 00535/2003/06 | Mariupol | 21.10.2003 |
21.10.2008 |
| G.M.D.S.S. General Operator (A-IV/2) Endorsement | 00535/2003/06 | Mariupol | 21.10.2003 |
21.10.2008 |
| Radar Observation and Plotting (A-II/1,2) | 1276 | Mariupol | 23.05.2000 |
23.05.2005 |
| Automatic Radar Plotting Aids (ARPA) (A-II/1,2) | 1536 | Mariupol | 23.05.2000 |
23.05.2005 |
| Carrying dangerous & hazardous cargo (B-V/4, B-V/5) | 000662-AS | Mariupol | 09.02.2001 |
09.02.2006 |
| Advanced Fire Fighting (A-VI/3) | 025413-AS | Mariupol | 06.10.2003 |
06.10.2008 |
| Proficiency in Survival Craft, Rescue Boats & Fast Rescue Boats | 040605-AS | Mariupol |
01.10.2003 |
01.10.2008 |
| Medical First Aid (A-VI/4-1) | 023773-AS | Mariupol | 09.10.2003 |
09.10.2008 |
| Ship Security Officer (ISPS) | 000109/2004/43 | Mariupol | 17.03.2004 |
17.03.2009 |
| Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7) | 009422 | Rostov-Don | 17.09.2001 |
21.09.2006 |
|
Name of vessel |
Company |
DWT |
Flag |
Type |
Position |
From |
To |
| Marfret Caraibes | Komrowski | 24000 | Luxemburg | Container | 2-nd Off | 14.05.2004 | 10.07.2004 |
| Helena Pride | Seatopaz Navigational | 24000 | Malta | Universal | 3-rd Off | 24.04.2002 | 25.10.2002 |
| Choyang success | Medallion Shipping | 35000 | Panama | Container | 3-rd Off | 03.04.2001 | 10.10.2001 |
| Abu Dabi Diamond | Oasis Ship Management | 4700 | Dubai | Container | 3-rd Off | 04.07.2000 | 25.12.2000 |
| Janda1 | Seabon Holding Co. | 14000 | Cyprus | Universal | R/Off | 06.06.1997 | 15.05.1998 |
| Experience at sea: Since 1996 | Knowledge Personal Computer: Yes | |||
| Medical Certificate: | ¹ | Issued: | Place: | Exp. date: |
| Vaccination for cholera valid until: | Vaccination for yellow fever valid until: 12.02.2006 | |||