POSITION TO APPLY FOR. CERTIFIED FOR. NAME / SURNAME. FATHER'S NAME. MOTHER'S NAME. D.O.B./P.O.B.. NATIONALITY. Height (in cm):182. Weight (Kg): 80. Shoes size: 42. Parka size: 48. ADDRESS. MARITAL STATUS. MARRIED. YES q NO n. CHILDREN. YES q NO

S E A M A N ' s A P P L I C A T I O N F O R M

A.SEAMAN'S PERSONAL DETAILS

POSITION TO APPLY FOR

Electrician

CERTIFIED FOR

Electro-technical rating

NAME / SURNAME

Yevhen Kos

FATHER'S NAME

Viktor

MOTHER'S NAME

Mariya

D.O.B./P.O.B.

28.08.1992 Nikolaev

NATIONALITY

Ukraine

Height (in cm):182

Weight (Kg): 80

Shoes size: 42

Parka size: 48

ADDRESS

15 Livanova pereulok Nikolaev Ukraine ZIP:54049

MOBILE No.:

PHONE No.:

+380932564336

SKYPE ADDRESS:

y.kos@icloud.com

MARITAL STATUS

MARRIED

YES q NO n

CHILDREN

YES q NO n

HOW MANY UNDER

18 YRS OLD ………

NEXT OF KIN

Viktor Kos

RELATION

Father

SEAMAN'S PASSP NO.

AB559351

ISS / VALID DATE

23.10.2015/ 2020

CIVIL PASSP NO.

EP323732

ISS / VALID DATE

29.08.2008

AUSTRALIAN MCV No.

ISS / VALID DATE

GRADUATED FROM

Odessa´s professional college of maritime transport

Makarov National University of Shipbuilding

ENGLISH ABILITY

FLUENT q

VERY GOOD q

GOOD n

FAIR q

B. NATIONAL CERTIFICATION
CERTIFICATE	NUMBER	ISSUING - VALIDATION DATE	ISSUING PLACE
CERTIFICATE OF COMPETENCY	12825/2016/07	07.07.2016	Nikolaev
ENDORSEMENT OF CERTIFICATE
GMDSS (DECK OFF.)
ENDORSEMENT OF GMDSS
SHIP SECURITY OFFICER
SHIP SECURITY AWARENESS		14.09.2015 – 14.09 2020	Ilychevsk
BASIC SAFETY		15.09.2015 – 15.09.2020	Ilychevsk
PROFICIENCY IN SURV CRAFT		23.02.2016 – 23.02.2021	Ilychevsk
MEDICAL FIRST AID
ADVANCED MEDICAL CARE
ADVANCED FIRE FIGHTING
RADAR (DECK OFF.)
ARPA (DECK OFF.)
C.O.W. / IGS
OIL TANKER SAFETY
CHEMICAL TANKER SAFETY
LPG SAFETY
LAST MEDICAL	CA 128-16	29.03.2016 – 29.03.2017	Nikolaev
VACCINATIONS	YELLOW FEVER : DOI …30.03.2016……… DOE …………………… CHOLERA : DOI …………………… DOE ……………………

C. FLAG CERTIFICATION
FLAG	TYPE / No. (S.BOOK/ENDORS/STICKER)	RANK	ISSUED	VALID	Based onNATIONAL ENDORSEMENT NUMBER
	/
	/

D. PREVIOUS SEA SERVICE
VESSEL	FLAG	TYPE/DWT	ENG/HP	RANK	S/ON	S/OFF	OWNERS

Seaman’s Signature……………………………