Sadama 4,
II Floor
TALLINN
Phone: ( +372 ) 640 9711
Fax: ( +372 ) 640 9748
e-mail: crew@tschudishipmanagement.com
APPLICATION FORM
PERSONAL DESCRIPTION AND INFORMATION
(Please write in English and in print letters)
   1.Name- Last: Iuriev First: Bogdan
 (As per Passport) Citizenship: Ukraina
   2.Date of Birth: 11/05/1970 Place: (City and Country): UKRAINE Nationality:UKRAINIAN
 3.Nearest Airport / Station: ODESSA
 4.Present Address: Odesskaya area,Ovidiopoliskiy rigion,selo Mizikevicha,str.Gemchygnaya 3,apt644
   Phone: Mobile: +380675586464,+380991900867
 5.Civil Status: Single-Married-Separated-Divorced-Widowed No.of Children NO
  6.Next of kin: Relation:
 7.Address of next of kin: THE SAME
  Ukrain. Odessa,str.Bazarnaya 120,apt.2 Phone: 0487261458 Mobile:+380677836082,+3809551665927
| 8.Wife and Children´s ( up to 18) Name
| Date of Birth
| Passport No.
| Date of Issue
| Date of Expiry
| Place of Issue
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  9.Position applied for: Date of Availability:
 Preferred contract length: Expected Salary:
 Preferred type of vessel: Preferred sailing region:
| 10.SCHOOL ATTENDED (including Pre-Sea Training)
| | Name of School
| Town/Country
| From (year)
| To (year)
| Type of degree/diploma received
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|    11.Passport number:Place of Issue: Issue Date: Expiry Date:
| 12.Seaman´s Book
| Number
| Date of Issue
| Date of Expiry
| Country of Issue
| | Estonian
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| | Russian
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| | Latvian / Lithuanian
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| | Ukraina
| AB520491
| 10.07.2013
| 10.07.2018
| UKRAINA
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| 13.Certificate of Competency
| Number
| Date of Issue
| Date of Expiry
| Country of Issue
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| | STCW Endorsement
| Number
| Date of Issue
| Date of Expiry
| Country of Issue
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| | Flag State Endorsement ( if any)
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| 14.Courses/Certificates
| Number
| Date of Issue
| Date of Expiry
| Place of Issue
| | BASIC SAFETY TRAINING
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| | DP CERT ( Basic, Advanced, Full)
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| | Proficiency in Survival Craft and Rescue Boats
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| | Fast Rescue Boat
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| | Advanced Training in Fire-Fighting
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| | Medical Emergency-First Aid
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| | Medical Care Onboard Ship
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| | GMDSS General Operator Certificate
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| | GMDSS General Operator Certificate(Endorsement )
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| | Radar Observer and Plotting Certificate
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| | ARPA
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| | Ship Security Officer
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| | Ship Safety Officer
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| | HAZMAT
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| | Bridge Team and Resource Management
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| | Ship Handling and Maneuvering
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| | ECDIS / Electronic charts
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| | BOSIET / HUET (OPITO)
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| | Maritime English
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| | Revalidation course
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| | Amos-D / Amos-W
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| | US VISA
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| | Yellow Fever
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Details of any courses/certificates not included in the above to be specified in spare or unutilized columns
15. PREVIOUS SEA SERVICES(Datewiseup to 10 previous vessels ending with last. Experience prior to that to be attached separately).
| Name of vessel
| Type of vessel
| Flag
| DWT
| Type of
Engine
| HP
| Name of Owners or Managers
| Rank
| From (day, month, year)
| To (day, month, year)
| | m/v JS Yangtse
| Bulk Carrier
| Singapore
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| Green ship Bulk
| Cook
| 30.03.2014
| 25.09.2014
| | m/v JS Loire
| Bulk Carrier
| Singapore
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| Green ship Bulk
| Cook
| 04.09.2013
| 06.03.2014
| | m/v JS Pomerol
| Bulk Carrier
| Valleta
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| Maypole shipping Limited
| Cook
| 26.11.2012
| 03.06.2013
| | m/v Colorado
| Bulk Carrier
| Singapore
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| Green ship Bulk
| Cook
| 31.03.2012
| 29.09.2012
| | m/v Genco Perenees
| Bulk Carrier
| Majuro
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| Genco Perenees Limited
| Cook
| 22.03.2011
| 21.10.2011
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| IRENEBALTIC MASTER
Elec.Officer to mention UMS Experience,if any:
Radio Officer to mention Radio Equipment make/Satcom/Telex:
16. References(Please indicate at least one person who could give additional information about You)
| No
| Name of referee
| Company
| Post
| Phone no
| | 1.
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Have you worked with mixed crew before? Yes ( ) No ( )
17.LANGUAGES (F: Fluent – M: Moderate) Spoken Written Read
 English
 Other -
Other -
18.PHYSICAL DECLARATION: Height: Weight: Color of Hair: Color of Eyes:
| Medical Inspection
| Date of Issue
| Date of Expiry
| Country of Issue
| | Estonian
| | | | | Other
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| Vaccination
| Date of Vaccination
| Date of Expiry
| Country of Issue
| | Yellow Fewer
| | | UKRAINE
| | Cholera
| | | | | Other
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19. Boiler Suit size:
T-Shirt size:
Working Shoes size:
“___” _______ _______________ 2014___ _______________________________
Date: 2016-04-22; view: 2000
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