Application form Motorman 2nd
POSITION
Motorman 2nd / Cadet
Surname
First name
Middle name
*********
VLADYSLAV
SERGEEVYSH
Date of birth
Place of birth
Citizenship
***********
Kherson, Ukraine
Ukrainian
Phone (mob.)
Nearest Airport
*******************
Kherson International Airport/
Odessa International Airport
Permanent address
Pokrysheva str. 14a, flat *****************0, Ukraine
Marital status (Married/Single/Divorced)
Number / age of children
Single
Next of kin (name/relation)
Next of kin address
********* INNA (mother)
Pokrysheva str. 14a, flat *****************0, Ukraine
Colors of eyes
Colors of hair
Special marks
Brown
Fair-haired
No
Height
Weight
Overall size
Shoes size
185
71
L
43
Knowledge of English (Fluent/Good/Satisfactory/Poor)
Other languages
Satisfactory
Russian, Ukrainian
Licenses & Certificates held
№
Date of issue
Date of expiry
Place of issue
Certificate off competency
Second class motorman
12400/2017/11
**********
Port of Kherson
Seaman’s passport
AB 593785
**********
**********
Port of Kherson
S’s Seagoing Serv. Rec. Book
************7
**********
Kherson
Travel passport
FF 549307
**********
**********
6512 (Kherson)
Basic safety
39188
**********
**********
Kherson
Proficiency in survival craft & Rescue boats
32875
**********
**********
Kherson
Designated security duties of shipboard personnel
31161
**********
**********
Kherson
Advanced fire fighting
27543
**********
**********
Kherson
Medical first aid on board ship
12517
**********
**********
Kherson
Schengen VISA
No
(Biometric Passport)
Last medical examination
**********
**********
Kherson
Details of previous sea service
Rank
Name of ship owner
Flag
Name of VSL
Type of VSL
DWT
From
To
cadet
Tad shipping Transport
Moldova
m/v Abubakar
Dry cargo
2478
**********p. Kherson
********** p. Kherson
Date: Signature ________________