Title: Form Manual
Operational Procedures Form
MSC CREWING SERVICES
MSC House, 92-v Lustdorfskaya road, Odessa 65088, Ukraine
Tel.: +38 (0482) 333 891
Fax.: +38 (048) 7055 200 / E-mail: info@[Link]
APPLICATION FORM
(Personal Data)
Position applied for: Junior officer License hold 4-6 months Date Available 20.08.2024
Family Name: Yakunin Name: Zakhar Father's name: Sergeevich
Date of birth: 12.12.2002 Place of birth: Reni (Ukraine ) Nationality: Ukrainian Marital status:
Address: Voznesenskaya 165/1 \, Reni (Odesa region) Nearest Airport:Bucharest Henri
Coanda International Airport, Home phone: +380688925899
Romania
E-mail: Mobile phone: +380636519684
zaharyakunin7@[Link]
Next of kin and relationship: Mariia Khadzhyohlo Children (name & DOB):
Next of kin’s address: Ukraine. Reni (Odesa region), [Link] street, house 22 Next of kin tel: +380734053543
Inter. P’port No :- Date of issue: - Valid: - Place of issue: -
Seaman's book No : 0231091 Date of issue: 02.08.2022 Valid: Place of issue: Izmail
Civil P’port No :- Date of issue: - Place of issue: -
USA visa No :- Date of issue: - Valid: - Place of issue: -
TOSE :- Date of issue: - MARLINS, %: Date of issue: -
SEA GOING EXPERIENCE FOR THE LAST 7 YEARS
(MOST RECENT VESSEL LAST)
Version 00/01 Feb 19 Page 1 of 2
Form CD-P03-1
Title: Form Manual
Operational Procedures Form
Year of Company Owner / Type of From To
Name of vessel Flag DWT / TEU ME type / Model BHP Rank
built Ship Manager vessel DD/MM/YYYY DD/MM/YYYY
Slovaki Deck 01.08.202
Agile 1995 DAIV TRADE
a Dry cargo 1650 28.11.2022
cadet 2
General Deck 14.12.202
Hermas 2000 Hermann Lohmann Cyprus 4903 13.06.2024
cargo cadet 3
Name of Maritime Institution attended Address of institution From To Degree of Diploma
Danube Institute of the National University Phanagoriis'ka St, 9, Izmail, Odesa Oblast, 26.09.2020 30.06.2024 -
"Odessa Maritime Academy" Ukraine
STCW Certificates Number Issued Valid Place of issue STCW Certificates Number Issued Valid Place of issue
Certificate of competency BRM or ERRM Course
Endorsement Basic safety for all seafarers 1563591 17.04.2023 17.04.2028 Odesa, Ukraine
GMDSS Endorsement Advanced fire fighting
Radar obs./ARPA operator Prof. in survival craft
ECDIS course Fast rescue boat 1563594 17.04.2023 17.04.2028 Odesa,Ukraine
Security officer (ISPS) Medical first aid
Security Designated Duties 1563596 17.04.2023 17.04.2028 Odesa,Ukraine Medical care
Hazardous cargoes 08.12.2023 31.12.2025 Izmail Training pers on [Link]
Medical examination Issued: 18.10.2023 Valid: 18.10.2024 Weight, kg: 82 kg Height, cm: 174
Drug & alcohol test Issued: 18.10.2023 Valid: 18.10.2024 Eyes: brown Hair: brown
Version 00/01 Feb 19 Page 2 of 2
Form CD-P03-1
Title: Form Manual
Operational Procedures Form
Yellow fever Issued: 18.10.2023 Valid: Overall size: M Safety shoes: 42
Another States Rank Document No Issued Valid Another States Certificates of Rank Document No Issued Valid
Seamen’s Books competency
Liberia Liberia
Panama Panama
Cyprus Deck cadet CY376003 07.02.2024 06.02.2034
Please complete addresses of your previous employers for references
Company Marlow Navigation Tel +380 4841 72787 Company Tel
Address Independence Avenue 3, Svyato-Nikolska St, 50, Izmail, Odesa Oblast, Address
Ukraine
Мій підпис підтверджує мою остаточну та безсуперечну згоду на обробку (збір, накопичення, зберігання, прийняття, систематизацію, використання, розподіл, поновлювання, змінення, знищення, кодування та будь-які інші
дії, необхідні для надавання посередницьких послуг з найму за кордоном і/або інших супровідних послуг) моїх особистих даних, що вказано в цій заявці з найму, а також будь-яких інших моїх особистих даних, що
надаються до ТОВ «ЕМ ЕС СІ КРЮЇНГ СЕРВІСЕС»
Signature________ ____________ Date ______20.06.2024__________ I understand, that my working contract will be canceled without notifying if any of submitted information
and documents are voted as false.
Nationalities of crew sailed with: Any
Version 00/01 Feb 19 Page 3 of 2
Form CD-P03-1