MARITIME AGENCY ”MARINE MAN”
Ukraine, Kherson
Petrenko 18 str. office 327
Phone/Fax: 80552 327660 PHOTO
Mobile phone : +380504944082
E-mail : crewingksua@[Link]
Application Form (Engineer) Position:
Name: Surname:
Date of birth: Place of birth:
Permanent address:
Phone:
Passport (OVIR): №: Place of issue: Date of issue: Valid until:
Seaman’s book:№: Place of issue: Date of issue: Valid until:
Citizenship: Expiry date of U.S. visa:
Marital Status: Married Single Divorced Widower
Next of kin: (name, pas. No)
Supported children under age of 18 1.
(name, surname, date of birth) 2.
Knowledge of English language: Very good Good Satisfactory Fair Poor
Other language knowledge:
Education: Qualification: No Diploma: Date of Issue:
College:
Academy:
Certificates of STCW 78/95 No. Place Date of issue Expiry date
Basic Safety Training
Proficiency in Survival Craft
Proficiency in Fast Rescue Boats
Advanced Fire Fighting
Medical First Aid
Medical Care
GMDSS Certificate
GMDSS Endorsement
Radar Observation & Plotting
Automatic Radar Plotting Aids
Dangerous & Hazardous Cargoes
Hazardous materials
Ships Safety Officer
Ships Security Officer
Isolating Breathing Apparatus
RO-RO Passenger Ship
RO-RO Ship
Oil Tanker Familiarization
Oil Tanker Specialized Training
Gas Tanker Familiarization
Gas Tanker Specialized Training
Chem. Tanker Familiarization
Chem. Tanker Specialized Training
1
Crude Oil Washing
Inert Gas Systems
Bridge Resource Management
Vapor Recovery Systems
Refresher & Updating
Maintenance of Electrical
and Electronic Engineering
Sea service (during five last years):
Name of vessel COMPANY DWT Flag Type Position Period of service
From To
1
2
3
4
5
6
7
Engine Experience
Automation Main Eng. Engine Aux. Engine Aux. Engine
Total Unmanned Without
(A1/A2) Maker/Model Stroke Maker/Number H.P. / KW
HP [Link].
1 /
2 /
3 /
4 /
5 /
6 /
7 /
National licenses ,Flag state passports, licenses, visas and other documents
Document Number Issued Valid Issued Place
CERTIFICATE OFCOMPETENCY
ENDORSEMENT
Experience at sea: Knowledge Personal Computer (Yes / No):
Medical Certificate № Issued: Place: [Link]:
Vaccination for cholera valid until: Vaccination for yellow fever valid until:
Ready to work from:_______________________
Your last salary –
Expected salary -
Date: ________________ Signature _____________________