SEAFARER APPLICATION FORM
Position applied for: OS________________
1 Surname : Slobodian 4 Date of birth : 29.06.2002
2 Name : Maksym 5 Place of birth : Russia
3 Given name : __________________ 6 Citizenship : Ukrainian
7 Address: Priluki ,Kopteva60/8
8 Phone No.(home) : +380663907140 9 Phone No.(contact):+380663907140
10 Seaman's ID No. : AB672095. 14 InterPassport No.: GA768404
11 Place of issue : Ukraine. 15 Place of issue : Ukraine
12 Date of issue : 17FEB2021. 16 Date of issue : 21JUL2021
13 Date of expiry : 17FEB2026. 17 Date of expiry : 21JUL2031
18 Marital status Single
19 Wife’s name : _______________ 20 Weight/Height : 80kg/183
21 Mother’s name : Svitlana
22 Education : Kiev state university of infrastructure and technology, ( bachelor’s
diploma) Navigator .
Medical first 1409805 30.12.2021 30.12.2026 Ukraine
aid
Safety ,Basic 272290 03.03.2021 03.03.2026 Ukraine
training
Survival crafts 1425568 31.01.2022 31.01.2027 Ukraine
and rescue boats
Security – 272291 03.03.2021 03.03.2026 Ukraine
Related training
Designated 1425559 31.01.2022 31.01.2027 Ukraine
security duties
Advanced fire 1409809 30.12.2021 30.12.2026 Ukraine
fighting
Certificate of 00102/2022/08 17.01.2022 17.01.2027 Ukraine
proficiency
Yellow fever - 15jan2021 During all life Ukraine
certificate of
vaccination
24 PROFESSIONAL EXPERIENCE DURING LAST 5 YEARS (in backwards order)
RANK MISSION MISSION SHIPOWNER/Nationality VESSEL DWT ME
STARTED COMPLETED Tel/Fax/e-mail Name & Type Type/BHP
12feb2022 18aug2022 Shipping company LTD Nicholas 56000
OS (Bulk carrier)
15oct2023 22apr2024 Navarone SA Sealion 32000
OS (Bulk carrier)
Minimum acceptable salary USD 1400$
I, undersigned, confirm all above information to be true and correct to my best knowledge:
Signature of the Applicant ____________________
CREW MANAGER REMARKS 1 2 3 4 5
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