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Dangerous cargoes certificates
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APPLICATION FORM
POSITION APPLIED FOR: _3rd engeneer
Personal data 12/06/16
| Family Name: Borys | Name: Sergey | Father's name: Sergey | ||||||
| Date of birth: 03/12/82 | Place of birth: Ukraine | Nationality: Ukraine | ||||||
| Marital status: married | Children (name & DOB): 2 | |||||||
| Address: Odessa Gimnazicheskaya 3/14a | Tel (including city code): | Mobile; +380677564150 Borys_sergey@mail.ru | ||||||
| Next of kin and relationship: Yliya -wife | ||||||||
| Next of kin’s address: Odessa Gimnazicheskaya 3/14a | Tel: +380675173756 | |||||||
| Inter. P’port No: РО652026 | Issued: 30/03/07 | Valid: 30/03/17 | Place of issue: Odessa | |||||
| Seaman's book No: BA473695 | Issued: 28/11/11 | Valid: 28/11/21 | Place of issue: Odessa | |||||
| Civil P’port No: KK254835 | Place of issue: Odessa | Date of issue: 25/05/99 | ||||||
| USA visa No: | Issued: | Valid: | Place of issue: | |||||
Medical information
| Medical examination | Issued: 25/05/16 | Valid: 25/05/17 | Weight, kg: 84 | Height, cm: 182 |
| Drug & alcohol test | Issued: | Valid: | Eyes: brown | Hair: brown |
| Yellow fever | Issued: 2007 | Valid: 2017 | Overall size: 54 | Safety shoes: 40 |
| Name of marine school attended | Address of school | From | To | Degree of diploma |
| Odessa school of a name Marinesko | Odesssa | 24.09.2010 | 19.11.2012 | Sudnomekhanik/third-class eng |
National License
| Certificate of competency hold | Number | Issued | Valid | Place of issue |
| Диплом | 30.01.2013 | |||
| Endorsement | 30.01.2013 | 31.12.2016 | Odessa |
| IMO | STCW Certificates | Number | Issued | Valid | Place of issue | ||
| GMDSS Endorsement | |||||||
| Carriage of dangerous and hazardous substances | 1141/2012 | 22.10.12 | 22.10.17 | Odessa | |||
| 1.08 | ARPA (A-I/12, A-II/1, A-II/2, B-I/12) | ||||||
| Personal safety (A-VI/1) (IMO 1.13, 1.19, 1.20, 1.21) | 26.01.2016 | 26.01.2021 | Odessa | ||||
| 2.03 | Advanced fire fighting (A-VI/3) | 1256/2012 | 23.10.2012 | 23.10.2017 | Odessa | ||
| 1.23 | Prof. in survival craft (A-VI/2 p.1-4) | 28.01.2016 | 28.01.2021 | Odessa | |||
| 1.14 | Medical first aid (A-VI/4-1) | 1032/2012 | 23.10.2012 | 23.10.2017 | Odessa | ||
| 1.15 | Medical care (A-VI/4-2) | 1032/2012 | 23.10.2012 | 23.10.2017 | Odessa | ||
| Hazardous cargoes (B-V/4, B-V/5) | 1141/2012 | 22.10.2012 | 22.10.2017 | Odessa | |||
| Safety officer (ISM code) | |||||||
| Crowd management (A-V/3) | |||||||
| Security training for seafarers with designated security duties | 03.02.14 | 03.02.19 | Odessa | ||||
| Training for person. serving onpassenger ships other than RO-RO pas.ships | 0630/2012 | 19.10.2012 | 19.10.2017 | Odessa | |||
| RoRo passenger (A-V/2-1, -2, -3, -4, -5) | 0434/2012 | 19.10.2012 | 19.10.2017 | Odessa | |||
| Ship handling arrangements | |||||||
| Свид-ство о повышении квалификации | |||||||
Dangerous cargoes certificates
| 1.01 | Oil tank. familiarization (A-V/1) | 0329/2012 | 26.10.2012 | 26.10.2017 | Odessa |
| 1.02 | Oil tank.Specialized training (A-V/1, p.9-14) | ||||
| 1.03 | Chem. tank. familiarization (V/1) | . | |||
| 1.04 | Chem. tank. advanced (A-V/1, p.16-21) | ||||
| 1.05 | LPG familiarization (V/1) |
PREVIOUS SEA SERVICES (last 5 years)
| Name of vessel | Year of built | Company | Flag | Type of vessel | DWT | Type of main engine | BHP | Rank | From Day, mont, year | To Day, month, year |
| First Brother | Fairwind Shipmanagement | Malta | Bulk carrier | Mitsubishi& MAN B& W | 4th eng | 05/03/13 | 06/06/13 | |||
| First Brother | Fairwind Shipmanagement | Malta | Bulk carrier | Mitsubishi& MAN B& W | 4th eng | 06/06/13 | 11/11/13 | |||
| Ocean brother | Fairwind Shipmanagement | Malta | Bulk carrier | Mitsubishi& MAN B& W | 4th eng | 12/03/14 | 27/08/14 | |||
| Lucky Trader | UMS (Germany) | ANT& BRB | Bulk carrier | Mitsubishi& MAN B& W | 4th eng | 03/11/14 | 06/02/15 | |||
| Lucky Trader | UMS (Germany) | ANT& BRB | Bulk carrier | Mitsubishi& MAN B& W | 3RD ENG | 17/05/15 | 30/10/15 | |||
| Another States Seamen’s Books | Rank | Document No | Issued | Valid | Another States Certificates of competency | Rank | Document No | Issued | Valid | |
| Liberia | Liberia | |||||||||
| Panama | Panama | |||||||||
| Malta | 22/02/13 | 31/12/16 | ||||||||
| ANTIGUA& BARBUDA | 04/05/2019 |
Please complete addresses of your previous employers for references
| Company | «Lirosa» | Tel: +380677161777 | Company | Fairwind Shipmanagement | Tel: +78123239133 |
| Address | Odessa | Address | Saint-petersburg |
Signature___B.S.S________ Date 30/12/15___ I understand, that my working contract will be canceled without notifying if any of submitted information and documents are voted as false.
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FOR OFFICIAL USE ONLY English abilities: Good: Average: Poor:
(To be filled by Company’s authorised personnel) 10 9 8 7 6 5 4 3 2 1
Good spoken and written Understand basic instructions Do not understand basic instructions
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