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Application form
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| Date | 31.03.2018 | | Size | 229.76 Kb. | | #44671 |
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APPLICATION FORM
Surname: Veselov
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First name: Yuriy
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Date of birth: 03.05.1971
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Place of birth: Russia, city Sevastopol
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Nationality: Russian
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Permanent Address: Sevastopol, Avenue. Heroes of Stalingrada, house 24-a apartment. 68
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Phone:
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Mob: +79787398466
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Email:vesel305@rambler.ru
| 2. GENERAL DETAILS
Document
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Number
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Date of issue
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Place of issue
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Date of Expire
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Passport
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751609239
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21.03.2016
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FMS 23201
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21.03.2026
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Seaman’s Book
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MK 0260432
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13.04.2016
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Novorossiysk
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Seaman’s Passport (Russian)
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0041907
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27.04.2016
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Novorossiysk
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26.04.2021
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US visa (C1/D)
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| 3. CERTIFICATES / QUALIFICATIONS
Grade/Class
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Number
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Date of issue
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Place of issue
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Date of expire
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Rank: Second Engineer Officer
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2015708576
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29.12.2015
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Novorossiysk
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27.11.2020
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Endorsement:
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Endorsement:
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Tanker Endorsement
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2015728520
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29.12.2015
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Novorossiysk
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18.12.2020
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4. EDUCATIONS
Date from | Date to |
Marine Academy (College)
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Certificates Obtained
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09/1993
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07.1999
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Sevastopol State Technical University
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5. ATTENDED DETAILS OF COURSES (FOR OFFICERS)
Course
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No of Certificate
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Date of issue
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Place of issue
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Date of expire
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Refresh Training for Officers
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| Basic Training (STCW95) |
AB 0362407
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05.07.2016
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Novorossiysk
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05.07.2021
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Advanced Fire Fighting
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AB 0363535
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11.07.2016
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Novorossiysk
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11.07.2021
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Survival Craft & Rescue Boats
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AB 0253486
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12.07.2016
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Novorossiysk
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12.07.2021
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Medical First Aid
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AB 0367971
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15.07.2016
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Novorossiysk
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15.07.2021
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Advanced training for oil tanker cargo operations
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AB 0293116
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18.12.2015
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Sevastopol
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18.12.2020
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SSO (ISPS Code)
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Radar Observer
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ARPA
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Hazmat for US
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Dangerous Goods
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Electronic Charts (ECDIS)
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Ship Security Officer
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AB 0545888
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30.06.2016
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Novorossiysk
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30.06.2021
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6. Flagstate seaman’s book
State
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Date of issue
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Place of issue
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Antigua & Barbuda
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German
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Norvegian
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Liberian
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Panamian
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7. MEDICAL FITNESS
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Date of issue
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Place of issue
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Date of expire
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Health Cert
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21.10.2016
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Sevastopol
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20.10.2017
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Yelow Fever
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06.09.2013
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Sevastopol
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06.10.2023
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8. PERSONAL DATA
Color of Eyes | Color of Hair |
Height
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Weight
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Size of Overall
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Size of shoes
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green
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black
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1.74
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79
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52
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43
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9. KNOWLEDGE OF LANGUAGES
(Indicate the level of your languages skills (3 = fluent, 2 = business, 1 = passable, 0 = very limited or none at all)
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Speaking
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Reading
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Writing
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English
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Computer Tests
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MARLINS
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CES4.1
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10. MARITAL STATUS: married, single, divorced, separated
Marital status: married
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Spouse Full Name: Veselova Anastasiya
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Address, Phone: Sevastopol, Avenue. Heroes of Stalingrada, +79787398545
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Number of childred uder 18 y.o.:
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1
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11. CONFIDENTIAL INFORMATION FOR OFFICE USE ONLY
Full Name of Next of Kin:
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Relationship:
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Address of Next of Kin: :
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Marital Status:
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Number of Children:
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12. SEA SERVICE (for last 5 years) please attach references for one/two last employment contract (if it is on hand).
FROM: dd.mm.yy
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TO:
dd.mm.yy
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Name of ship
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Blt yyyy
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Flag
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DWT
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KWT
Engine type
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Owner or Managers
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09/2008
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03/2009
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Kurs
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Ukrain
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4200
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B&W 3200
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reefer
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motorman
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Atlantika
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07/2009
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01/2010
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Azov
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Ukrain
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2219
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8NVD48 1160
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cargo ship
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motorman
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Linart
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10/2011
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03/2012
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Pechera
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Ukrain
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3000
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6LU35G 1500
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cargo ship
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third engineer
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Trading house «Betonstroi»
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11/2012
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02/2013
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Pechera
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Ukrain
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3000
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6LU35G 1500
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cargo ship
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third engineer
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Trading house «Betonstroi»
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09/2013
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05/2015
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Iman
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Russia
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4500
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B&W 3200
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Bunkering tanker
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second engineer
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supply fleet Russion
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05/2015
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05/2016
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Iman
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Russia
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4500
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B&W 3200
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Bunkering tanker
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second engineer
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supply fleet Russion
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DATE: 21.10.2016 SIGNATURE:
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