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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 / Seamanís Passport   Ukraine ab499350 24.02.12 14.02.17     Yellow Fever Vaccination  
Other Seamanís Book     15. TESTS  
Other Seamanís 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.


Date: 2016-03-03; view: 488


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