Position Applied For

Position applied for

SEAWHALE CO LTD

Date of availability

ARKHANGELSK, RUSSIA

Crew Application PART I. PERSONAL DESCRIPTION AND INFORMATION: 1. LAST NAME

5.ADDRESS

2. FIRST NAME

3. MIDDLE NAME

RUSSIA,

8. NATIONALITY

4. DATE AND PLACE OF BIRTH

6. TEL./FAX 9. HEIGHT

10. WEIGHT

11. COLOUR OF EYES

7. CONT. TEL. 12. COLOUR OF HAIR

RUSSIA 13. MARITAL STATUS

14. № OF CHILDREN

15. NEXT OF KIN (Name, Relationship)

16. ADDRESS AND TELEPHONE OF PERSON NAMED IN 15 (if same as 5, write "the same")

THE SAME

Address:

THE SAME

Tel:

PART II. PASSPORTS: DOCUMENT

DOCUMENT №

PLACE ISSUED

DATE ISSUED

EXPIRY DATE

DATE ISSUED

EXPIRY DATE

DATE ISSUED

EXPIRY DATE

Russian Seamans Passport Travel Passport Civil (National) Passport

PART III. VISAS: DOCUMENT

Valid Schengen Visa Valid German visa Valid USA Visa

PART IV. NATIONAL LICENSES: DOCUMENT

GRADE

DOCUMENT №

PLACE ISSUED

DATE ISSUED

EXPIRY DATE

Certificate of Competency Endorsement (TANKER) Certificate of Competency

PART V. CERTIFICATES: CERTIFICATE

DATE ISSUED

CERTIFICATE

DATE EXPIRED

Basic Training (SOLAS Certificate)

ARPA

Proficiency in Survival Craft

Radar Observer

Advanced Fire Fighting

Tankerman oil Familiarization

Medical First Aid (specialized)

Tankerman oil Advanced

Medical Care

Bridge Team & Resource Management

GMDSS

Ship Security Officer course

Endorsement of GMDSS (date of validy)

English course

DATE ISSUED

DATE EXPIRED

PART VI. MEDICAL EXAMINATION: DATE ISSUED

EXPIRY DATE

DATE ISSUED

Medical Examination Yellow Fever

PART VIII. REMARKS: IF YOU HAVE CERTIFICATES THAT IS NOT INDICATED IN PART V. PLS INSERT DATA HERE: CERTIFICATE DATE ISSUED DATE EXPIRED 1 Salary expectation? 2 3 4 5 6

EXPIRY DATE

PART IX. FOREIGN DOCUMENTS:

License Date of Applying

Seamans Book License GMDSS Medicine Date of Applying

No

GIBRALTAR Date of issue Date of expire

Capacity

No

ANTIGUA & BARBUDA Date of issue Date of expire

Capacity

X

X No

License Date of Applying

Seamans Book License GMDSS Medicine Date of Applying

Seamans Book License Solas Surv.crafts Medicine Date of Applying

Seamans Book License Date of Applying

License Date of Applying

Date of expire

Capacity

NETHERLANDS ANTILLES Date of issue Date of expire

Capacity

X No

Seamans Book License Date of Applying

MADEIRA Date of issue

X No

GERMANY Date of issue

Date of expire

Capacity

No

LIBERIA Date of issue

Date of expire

Capacity

No

CYPRUS Date of issue

Date of expire

Capacity

No

ST. VINCENT Date of issue Date of expire

Capacity

X

X

X

X

PART X. SEA SERVICE: List and submit proof of sea service during the last 10 (ten) years RANK

NAME OF VESSEL

AB'S

JULIETTA

Vessel Type

GOD

Engine Type

DWT

5600

7406

Kilowatts

PERIOD OF SERVICE

FLAG

NAME OF CREWING AGENT/ SHIPPING COMPANY

A&B

ASKOLDAS INTERNATION

2003 2003 09 21

ASKOLDAS INTERNATION

2004 2005 02 21

2001

2002

LIMITED COMPANY OILER

ATLANTIC DOWN

FACTORY

_____

____

_____

IRELAND

NOVIKONTAS LIMITED CO

2003 04

2008 10 01

OS SEAMAN AB'S COOK

PART XI. NAUTICAL, ENGINEERING OR RADIO SCHOOL AS ATTENDED: Name of School

Address

MARINE COLEGE

KLAIPEDA LITHUANIA

Dates attended From

To

Type of degree of Diploma received upon Graduation

2002

2005

PORT OPERATION DEPRTM. EUROPEAN LEVEL

2009 8:38 OLEG MURE NKOV NIKO Date

Name, Signature of Seafarer