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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
3rd officer
DATE OF READY
04/05/2017
NAME / SURNAME
Goryelov Oleksandr
FATHER'S NAME
Oleksandr
MOTHER'S NAME
Anna
D.O.B./P.O.B.
18/10/1989 Ukraine
NATIONALITY
Ukraine
Height (in cm):165
Weight (Kg):74
Shoes size:40
Parka size:L
ADDRESS
Ukraine Kherson Vostochnaya29/29(d)
MOBILE No.:
PHONE No.:
[open contact info](look above in the "contact info" section)
VIBER ADDRESS:
[open contact info](look above in the "contact info" section)

MARITAL STATUS

MARRIED
YES x NO 
CHILDREN
YES x NO 
HOW MANY UNDER
18 YRS OLD ………
NEXT OF KIN
Goryelova Anastasiya
RELATION
Wife
SEAMAN'S PASSP NO.
AB 389317
ISS / VALID DATE
13 Aug 2008/25 Jul 2018
CIVIL PASSP NO.
MP 163819
ISS / VALID DATE
15 Feb 2006/
Tourist PASSP NO.
EE 650452
ISS / VALID DATE
29 Oct 2008/29 Oct 2018
GRADUATED FROM

ENGLISH ABILITY
FLUENT 
VERY GOOD 
GOOD x
FAIR 

B. NATIONAL CERTIFICATION
CERTIFICATE
NUMBER
ISSUING - VALIDATION DATE
ISSUING PLACE
CERTIFICATE OF COMPETENCY
12043/2016/11
27/05/2016-25/05/2021
Ukraine
ENDORSEMENT OF CERTIFICATE
12043/2016/11
27/05/2016-25/05/2021
Ukraine
GMDSS (DECK OFF.)
10771/2016/11
21/03/2016-11/03/2021
Ukraine
ENDORSEMENT OF GMDSS
10771/2016/11
21/03/2016-11/03/2021
Ukraine
SHIP SECURITY OFFICER
936/MPS
29/01/2016-29/01/2021
Marine pro service
SHIP SECURITY AWARENESS
11940/2016/11
27/05/2016-22/04/2021
Ukraine
BASIC SAFETY
19608/MPS
29/01/2016-29/01/2021
Marine pro service
PROFICIENCY IN SURV CRAFT
15252/MPS
29/01/2016-29/01/2021
Marine pro service
MEDICAL FIRST AID
2255/MPS
29/01/2016-29/01/2021
Marine pro service
ADVANCED MEDICAL CARE

ADVANCED FIRE FIGHTING
12571/MPS
29/01/2016-29/01/2021
Marine pro service
ECDIS (DECK OFF.)
1491/MPS
29/01/2016-29/01/2021
Marine pro service
ARPA (DECK OFF.)
588/MPS
29/01/2016-29/01/2021
Marine pro service
BRIDGE RESOURCE MANAGEMENT
6386/MPS
10/02/2016-10/02/2021
Marine pro service
TRAINING OF PASSENGER SHIP PERSONNEL
1581/MPS
29/01/2016-29/01/2021
Marine pro service
TRAINING OF OFFICERS AND RATINGS RESPONSIBLE FOR CARGO HANDLING ON SHIPS CARRYING DANNGEROUS AND HAZARDOUS SUBSTANCE IN SOLID FORM IN BULK AND IN PACKAGED FORM
7424/MPS
29/01/2016-29/01/2021
Marine pro service
ENGLISH LANGUAGE TEST
THE TEST RESULT
LOCENCE CODE
TEST DATE
MARLINS TEST
79%
2AE5838E95DA7D42
13/FEB/2014
VACCINATIONS

YELLOW FEVER : DOI 19 JAN 2009 DOE 19 JAN 2019
POLIOMYELITIS : DOI 19 MAY2015 DOE

C. FLAG CERTIFICATION
FLAG
TYPE / No.
(S.BOOK/ENDORS/STICKER)
RANK
ISSUED
VALID
Based on NATIONAL
ENDORSEMENT
NUMBER
Union des Comores
Endorsement /10771/2016/11
3rd officer
26/AUG/2016
11/MARC/2021
16/ENDORS/DEC/1137
Republica de Panama
S.book/ /EE 650452
Ordinary seaman
22/MAY/2015
21/MAY/2020
1092157 PG

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

Comoros

General cargo/2457

3rd officer

15 JUN 2016

16 OCT 2016

Talex LTD

m/v Tychy
Panama
Ro-Ro/4810

O/S

25 May 2015

10 OCT 2015

Reefer and general ship management coinc.

m/v Camilla
Gibraltar
Container ship/16801

O/S
22 FEB 2014
21 OCT 2014
Altair navigation limited
m/v Fiona
Gibraltar
Container ship/16801

O/S
21 OCT 2012
30 APR 2013
Sirius Navigation LTD Gibraltar
m/v Tychy
Panama
Ro-Ro/4810

O/S
18 JAN 2012
06 AUG 2012
Maritime operators inc.Monrovia,Liberia
m/v Pylaros
Panama
Bulk carrier/44985

O/S
20 AUG 2010
05 FEB 2011
Pylaros shipping S.A.,Marshall Islands
m/v Leader
Gibraltar
container ship/17618

cadet
30 JAN 2009
02 AUG 2009
Entry shipping S.A. Mojuro,Marshall Islands

Version: 1/13 Seaman’s Signature Goryelov Oleksandr