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National License
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APPLICATION FORM
POSITION APPLIED FOR: Deck cadet /Ordinary Seaman
Personal data English: good
| Family Name: Moskalenko | Name: Artem | Father's name: Pavlovych | ||||||
| Date of birth: 31.08.1996 | Place of birth: Kherson region | Nationality: Ukrainian | ||||||
| Marital status: single | Children (name & DOB): 0 | |||||||
| Address: 25, 40 Rokіv Zhovtnya str, Kherson region, Ukrain | E-Mail: artemmoskalenko0@gmail.com | Mobile: +380994547118 +380687925899 | ||||||
| Next of kin and relationship: Pavel Leonidovich Moskalenko -father, Natalya Grigorevna Moskalenkо -mather | ||||||||
| Next of kin’s address: Kakhovka district, Kherson region, Ukraine | Tel: +380997016542 | |||||||
| Inter. P’port No: FA242930 | Issued: 23.04.2015 | Valid: 23.04.2025 | Place of issue: Kherson, Ukrain | |||||
| Seaman's book No: AB566620 | Issued: 16.12.2015 | Valid: 14.04.2020 | Place of issue: Kherson, Ukrain | |||||
| Civil P’port No: МR388173 | Place of issue: Kherson, Ukrain | Date of issue: 02.11.2012 | ||||||
| USA visa No: | Issued: | Valid: | Place of issue: | |||||
Medical information
| Medical examination | Issued: | Valid: | Weight, kg: 75 | Height, cm: 179 |
| Drug & alcohol test | Issued: | Valid: | Eyes: brown | Hair: black |
| Yellow fever | Issued: | Valid: | Overall size: XL | Safety shoes: 42 |
| Name of marine school attended | Address of school | From | To | Degree of diploma |
| Maritime College of Kherson State Maritime Academy | 20, Prospect Ushakova, Kherson, Ukraine |
National License
| Certificate of competency hold | Number | Issued | Valid | Place of issue |
| Диплом | ||||
| Endorsement |
| STCW Certificates | Number | Issued | Valid | Place of issue |
| Safety Familiarization, Basic training and instruction for all seafarers | 23880/15KH | 23.01.2015 | 23.01.2020 | UKRAINE ODESSA MARITIME TRAINING CENTRE KHERSON BRANCH |
| Advanced fire fighting | 11748/15KH | 10.04.2015 | 10.04.2020 | UKRAINE ODESSA MARITIME TRAINING CENTRE KHERSON BRANCH |
| Medical first aid on board ship | 9446/15KH | 09.04.2015 | 09.04.2020 | UKRAINE ODESSA MARITIME TRAINING CENTRE KHERSON BRANCH |
| Proficiency in survival craft and rescue boats other than fast rescue boats | 18695/15KH | 13.02.2015 | 13.02.2020 | UKRAINE ODESSA MARITIME TRAINING CENTRE KHERSON BRANCH |
| Security-related training and instruction for all seafarers | 1390/15KH | 18.02.2015 | UKRAINE ODESSA MARITIME TRAINING CENTRE KHERSON BRANCH | |
| Designated security dutirs of shipboard personnel | 1390/15KN | 18.02.2015 | UKRAINE ODESSA MARITIME TRAINING CENTRE KHERSON BRANCH |
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 |
| «OM-106" | Kherson State Maritime Academy | Ukraine | passenger ship | 21.5t | Diesel | deck cadet | 03.06.2015 | 31.08.2015 | ||
| Another States Seamen’s Books | Rank | Document No | Issued | Valid | Another States Certificates of competency | Rank | Document No | Issued | Valid | |
| Liberia | Liberia | |||||||||
| Panama | Panama | |||||||||
Please complete addresses of your previous employers for references
| Company | «Kherson State Maritime Academy» | (Tel: 22-56-66 | Company | Tel: | |
| Address | 20, ave. Ushakova, Kherson, Ukraine | Address |
Signature____________________ Date ________________ 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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