Your application will not be accepted unless it complies with all the above requirements.
OTHER PERSONAL DATA
a) Height 173
b) Weight 65
c) Boots Size 40
d) Overall Size 46
e) Color of Eyes brown
f) Color of Hair brown
MARITIME EDUCATION
Educational institution
Specialty
Place
Period of Studies
From
To
Courses School X College Academy
Navigation
Ukraine
01.09.2010
14.06.2013
CERTIFICATES OF COMPETENCY
Grade / Class/STCW Code
Number
Date of Issue
(DD.MM.YY)
Date of Expire
(DD.MM.YY)
Country
Certificate of Competence:
00393/2013/11
13.05.2013
Ukraine
Endorsement:
00393/2013/11
13.05.2013
Ukraine
Basic Safety Course (VI/1)
22007/13KH
21.06.13
21.06.18
Ukraine
Advanced Fire Fighting (VI/3)
10178/13KH
21.06.13
21.06.18
Ukraine
X Medical First Aid (VI/4-1) Medical Care (VI/4-2)
8352/13KH
21.06.13
21.06.18
Ukraine
Survival Craft and Rescue boats (VI/2-1)
17015/13KH
20.06.13
20.06.18
Ukraine
Proficiency in Fast Rescue Boats (VI/2-2)
Tankerman Oil X Familiarization Advanced
Tankerman Chemical Familiarization Advanced
Tankerman Gas Familiarization Advanced
ARPA X Operational Management
2536/13/KH
01.06.13
01.06.18
Ukraine
GMDSS General Operator
Bridge Engine X Resource Management
Maneuvering & Ship Handling
Welder Electro X Gas TIG
ECDIS
1966/13KH
27.06.13
27.06.18
Ukraine
Ship Security Officer X Designated Security Duties
Please turn over and complete the reverse side.
13. PASPORTS AND VISAS(Please OBLIGATORY advise the complete details of your passports) 14.MEDICAL CERTIFICATE AND VACCINATIONS
Type
Country
Serial Number
Date of Issue
(DD.MM.YY)
Date of Expire
(DD.MM.YY)
Date of Issue
(DD.MM.YY)
Date of Expire
(DD.MM.YY)
National Passport
Ukraine
ep132260
06.07.12
06.07.22
Medical Certificate
18.12.15
18.12.16
Tourist / Travel Passport
Drug & Alco Test Certificate
18.12.15
18.12.16
Seaman's Book / Seaman’s Passport
Ukraine
ab499350
24.02.12
14.02.17
Yellow Fever Vaccination
Other Seaman’s Book
15. TESTS
Other Seaman’s Book
MARLINS test result
%
date
US Visa C1/D
CES 4.1 test result
%
date
Schengen Visa
16. PREVIOUS SEA SERVICE(Please submit the complete information about your service at sea during last five years)
Owners or Managers
Vessel's name
Type of vessel
Flag
GRT
Kwt
Type of Engine
Rank
Sign-on
(DD.MM.YY)
Sign-off
(DD.MM.YY)
Nibulon
Prybuzanivskyy
Tug
Ukraine
Cadet
05/06/11
26.08.11
Concord shiping corporation
Chelsea 1
GC
Malta
2x287
A1
OS
01.09.12
05.02.13
Sea star 1
Bislan
GC
Moldova
2x485
A1
AB
21.02.14
31.05.14
Sea star 1
Alvadi 1
GC
Ukraine
2x505
A1
AB
25.06.14
14.11.14
Mazandaran shiping co.
Nazmehr
GC
Iran
2x515
A1
AB
15.02.15
08.09.15
DECLARATION:I do hereby declare that all the above statements are complete and correct to the best of my knowledge. I do understand that this application form contains information vital for my further employment, however, its presenting gives me no guarantee for such unless proper requirement available. I do also understand that the below assessments of my qualifications and knowledge will affect my ability to be employed via LAPA Ltd.
DATE OF APPLICATION:
13.01.2016
SIGNATURE:
WHILE SUBMITTING YOUR APPLICATION
· Please attach: the originals of all the documents you have indicated above, all of your passports, your medical book, and your vaccination book.
· Have your tests passed.
Your application will not be accepted unless it complies with all the above requirements.
THANK YOU! DO NOT WRITE ON THE SPACE BELOW!
Test in English
passed (date):
Score:
Authorized
signature:
Professional Competence Test
passed (date):
Score:
Authorized
signature:
This application form is property of LAPA Limited Company. No copies of this form will be accepted by the company. All rights for duplication and distribution are reserved. "LAPA" is the registered trademark of LAPA Limited Company. Form F1.1., research by VMO 2007.