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Application form
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| Position Applied for: Motorman-Oiler | Date Available from: 15.01.2016 |
| Personal Data | ||
| Family Name: Dmytriiev | First Name: Aleksandr | Middle Name: Andreevych |
| Date of Birth: 13.06.1993 | Place of Birth (City and Country): Ukraine, Kherson | Citizenship: Ukraine |
| Permanent Address: Ukraine, Kherson, 6 - Tekstilna. 62 Skype: voloshina.19821 saniya-dmitrik | Phone (Home): Phone (Business/ Mobile): +380956950597 +380666964091 E-mail: aleksander.dmitri2016@yandex.ru |
| Maritime Education | |||||
| Name of school | Town | Country | From | To | Type of degree or diploma |
| Professional Maritime Lyceum of Kherson State | Kherson | Ukraine | 1.09.2010 | 30.11.2011 | Second class Motorman |
| Professional Test | ||
| English Test Date | Name of Test | Score |
| Professional Test Date | Name of Test | Score |
| Professional Interview Date | Result |
| Family Details | |
| Civil Status: Not Married | |
| Next of Kin: Mother Dmitriieva Irina, Ukraine, Kherson, 6-Tekstilna 62, +380663359332 | Relationship Not Married |
| Address of Residence Ukraine, Kherson, 6 - Tekstilna. 62 | Phone +380666964091 |
| Family Name | Dmitriieva | Voloshina | Desna | ||
| First Name | Irina | Elena | Luidmila | ||
| Date of Birth | 18.10.1970 | 14.08.1982 | 06.04.1991 | ||
| City of living | Kherson | Kherson | Kherson | ||
| Phone Numbers | +380663359332 | +380502773370 | +380956950597 |
| Identity Documents | |||||
| Document | Country | Number | Place of Issue | Issue Date | Expiry Date |
| Seaman's Book | Ukraine | AB 498817 | Kherson | 24.01.2012 | 24.01.2017 |
| Travel Passport | Ukraine | FA 108697 | Kherson | 03.03.2015 | 03.03.2025 |
| Civil Passport | Ukraine | MP 297751 | Kherson | 19.09.2009 |
| Courses Attended and Certificates Obtained | ||||
| Document | Number | Dates | Place | |
| Issue | Expiry | |||
| Certificate of Competency | 10681/2015/11 | 13.03.2015 | Kherson | |
| Maltese Endorsement of COC | ||||
| Oil Tanker Endorsement | ||||
| Chemical Tanker Endorsement | ||||
| Gas Tanker Endorsement | ||||
| Oil Tanker Familiarization Training | ||||
| Security Training and Instruction | 13.02.2015 | 13.02.2020 | Kherson | |
| Gas Tanker Familiarization Training | ||||
| Oil Tankers Specialized Training | ||||
| Chemical Tanker Specialized Training | ||||
| Gas Tanker Specialized Training | ||||
| Basic Trainings | ||||
| Proficiency in Survival Craft and Rescue Boats | 13.02.2015 | 13.02.2020 | Kherson | |
| Basic Safety Instruction | 13.02.2015 | 13.02.2020 | Kherson | |
| Medical First Aid Training | ||||
| Medical First Aid Training and Medical Care | ||||
| GMDSS | ||||
| GMDSS Endorsement | ||||
| Security Duties Personnel | 13.02.2015 | 13.02.2020 | Kherson | |
| Automatic Radar Plotting Aids Simulator (ARPA) | ||||
| Bridge Team Management | ||||
| Shiphandling & Maneuvering | ||||
| Ship Security Officer Training Course | ||||
| Maltese Endorsement of SSO | ||||
| ISM Code | ||||
| Safety Officer | ||||
| Ecdis Training Course | ||||
| Risk Assessment Course | ||||
| C.O.W./ I.G.S | ||||
| Fire Practice on Tankers | ||||
| Vapour Recovery System | ||||
| Unmanned Machinery Space | ||||
| FRAMO Familiarization Course | ||||
| Cargo Ballast Operations on Oil/Chemical Tankers | ||||
| Hazardous Materials | ||||
| Welder | ||||
| Turner |
| Physical Data | |
| Height | |
| Weight | |
| Colour of Hair | brown |
| Colour of Eyes | green |
| Boilersuit Size | |
| Shoes Size |
| Medical History | Yes | No |
| Have you ever signed off a ship due to medical reasons? | no | |
| Did you undergo any medical operation in the past? | no | |
| Have you consulted a doctor during the last 12 months for an illness/accident? | no | |
| Do you have any health or disability problems now? | no |
| If yes, please give full details: |
| Passed: | Valid till: | |
| International Medical Examination | 31.07.2015 | 31.07.2016 |
| Vaccination Against Yellow Fiver | ||
| Vaccination Against Diphtheria | ||
| References (please give name and address of your current or past employer) | Office remarks |
| Name of Company | Poseidon | |
| Name of person to contact | Zelinski A.G. | |
| Address | Kherson | |
| Phone |
| Name of Company | Svitova Line | |
| Name of person to contact | DouchingA.V. | |
| Address | Kherson | |
| Phone |
| Name of Company | UKRFERRY | |
| Name of person to contact | Kushnarenko O. | |
| Address | Ilichvsk | |
| Phone |
| Knowledge and experience | Yes | No |
| OCIMF vetting experience: | ||
| ISGOT knowledge: |
| I hereby declare that the above, including Medical History, is true | ||
| Place | Date | Signature |
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