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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
         
           
           
           

 

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
         
         

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        
Russian        
Latvian / Lithuanian        
Ukraina AB520491 10.07.2013 10.07.2018 UKRAINA

 

 

13.Certificate of Competency Number Date of Issue Date of Expiry Country of Issue
         
         
STCW Endorsement Number Date of Issue Date of Expiry Country of Issue
         
         
Flag State Endorsement ( if any)        
         

 

14.Courses/Certificates Number Date of Issue Date of Expiry Place of Issue
BASIC SAFETY TRAINING        
DP CERT ( Basic, Advanced, Full)        
Proficiency in Survival Craft and Rescue Boats        
Fast Rescue Boat        
Advanced Training in Fire-Fighting        
Medical Emergency-First Aid        
Medical Care Onboard Ship        
GMDSS General Operator Certificate        
GMDSS General Operator Certificate(Endorsement )        
Radar Observer and Plotting Certificate        
ARPA        
Ship Security Officer        
Ship Safety Officer        
HAZMAT        
Bridge Team and Resource Management        
Ship Handling and Maneuvering        
ECDIS / Electronic charts        
BOSIET / HUET (OPITO)        
Maritime English        
Revalidation course        
Amos-D / Amos-W        
US VISA        
Yellow Fever        

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       Green ship Bulk Cook 30.03.2014 25.09.2014
m/v JS Loire Bulk Carrier Singapore       Green ship Bulk Cook 04.09.2013 06.03.2014
m/v JS Pomerol Bulk Carrier Valleta       Maypole shipping Limited Cook 26.11.2012 03.06.2013
m/v Colorado Bulk Carrier Singapore       Green ship Bulk Cook 31.03.2012 29.09.2012
m/v Genco Perenees Bulk Carrier Majuro       Genco Perenees Limited Cook 22.03.2011 21.10.2011
                   
                   

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.        
2.        

 

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      

 

Vaccination Date of Vaccination Date of Expiry Country of Issue
Yellow Fewer     UKRAINE
Cholera      
Other      

 

19. Boiler Suit size:

XXL
XL
L
S
M
T-Shirt size:

Working Shoes size:

“___” _______ _______________ 2014___ _______________________________


Date: 2016-04-22; view: 1758


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