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APPLICATION FORM


Position applied for _3 off_

Date of availability 25.02.2012 _

NAME: Khrystofor

SURNAME: Guzev


DATE/PLACE OF BIRTH: 16.011987 Sevastopol

NATIONALITY: Ukraine

INTERNATIONAL PASSPORT: EC 546325

ISSUED/VALID: 11.05.2006/11.05.2016

SEAMAN’S BOOK: AB396128

ISSUED/VALID: 02.11.2010/02.11.2015

US VISA: EC 546325 from11.01.12 till 10.01.17

MOBILE NO: 0509296678;0665059787

FOREIGN CREW EXPERIENCE: YES__ NO _X_

ENGLISH: GOOD___ AVERAGE_X_ POOR___


STCW CERTIFICATES


REGULATION

NUMBER

ISSUED / VALID

PLACE OF ISSUE

CERTIFICATE OF COMPETENCY




00052/2008/09

05.08.2008

Sevastopol

ENDORSEMENT




00052/2008/09

05.08.2008/19.06.2013

Sevastopol

G.M.D.S.S. OPERATOR CERTIFICATE

IV / 2

00017/2008.09

05.08.2008

Sevastopol

G.M.D.S.S. OPERATOR ENDORSEMENT

IV / 2

00017/2008.09

05.08.2008/20.05.2013

Sevastopol

BASIC SAFETY TRAINING

A – VI / 1

08005C

16.05.2008/17.05.2013

Sevastopol

PROFICIENCY IN SURVIVAL CRAFT

A – VI / 2

05374C

16.05.2008/17.05.2013

Sevastopol

ADVANCED FIRE FIGHTING

A – VI / 3

04988C

16.05.2008/17.05.2013

Sevastopol

MEDICAL CARE ON BOARD

A – VI / 4










MEDICAL FIRST AID

A – VI / 4

02410C

16.05.2008/17.05.2013

Sevastopol

A.R.P.A. (RADAR SIMULATOR)

A – II / 1

0431C

17.05.2008/18.05.2013

Sevastopol

CHEMICAL TANKERS SAFETY

V / 1










CRUDE OIL WASHING

MARPOL-73/78










INERT GAS SYSTEM

MARPOL-73/78










HAZARDOUS CARGOES

B-V/4&B-V/5










ISM (INTERN. SEAMAN’S CODE)

A.1441 (18)










RO – RO PASSENGER SHIPS

A – V / 2










SHIP’S SAFETY OFFICER













SHIP’S SECURITY OFFICER













ELECTICAL & ELECTRONIC EQUIPMENT













BREATHING APPARATUS














SEA SERVICE

^ NAME OF VESSEL

NAME OF COMPANY

FLAG


TYPE OF VESSEL


TYPE OF ENGINE


BHP (Kwt)

D.W.T.

RANK

DURATION OF

SERVICE

FROM

TO

Salgir

YRTF

Cyprus

Reefer

B&W

3783

4241

Deck cadet

17.05.07

30.12.07

Lira

Yugreftransflot

Slovakia

Gen. cargo

MAK

1360

3051

3 off

25.08.08

14.12.08

Bukhta Omega

YRTF

Panama

Reefer

B&W

5397

7469

3 off

28.01.09

28.07.09

Angara

YRTF

Vanuatu

Reefer

B&W

4204

4258

2 off

26.02.10

21.08.10























































































































































































^ OTHER PASSPORTS

UKRAINIAN PASSPORT:

AP 337867

ISSUED:

23.02.2003

PANAMA PASSPORT:




ISSUED / VALID:




PANAMA ENDORSEMENT:




ISSUED / VALID:




LIBERIAN PASSPORT:




ISSUED / VALID:




LIBERIAN ENDORSEMENT:




ISSUED / VALID:




CYPRUS PASSPORT:




ISSUED / VALID:




CYPRUS ENDORSEMENT:




ISSUED / VALID:




VANUATU PASSPORT

70508

ISSUED / VALID:

01.03.2010/19.01.2013

VANUATU ENDORSMENT

10-56260

ISSUED / VALID:





PERSONAL DATA

MARITAL STATUS: MARRIED____ SINGLE___X__ DIVORCED____ WIDOWED_____


WIFE’S NAME:

HOME ADDRESS:

NEAREST AIRPORT: Simferopol

PHONE NO:

(0692)432802; (0652)516705

E- MAIL:

kifnidy@mail.ru

MOBILE NO:

0509296678; 0665059787

NEXT OF KIN:

Aleksandr

CONTACT NO:

0509690959

ADDRESS OF THE NEXT OF KIN: 48 P.Korchagin str, ap56

FATHER’S NAME:

Aleksandr

MOTHER’S NAME:

Elizaveta

CHILDREN: SONS__ DAUGHTERS___

NAMES OF CHILDREN:




HEIGHT:

73

WEIGHT:

185

SHOES:

44

OVERALL SIZE:




EYE COLOR:

brown

HAIR COLOR:

black

YELLOW FEVER:

01.06.2006/01.06.2016

LAST MEDICAL EXAMINATION:




MARLIN’S TEST:

85 %
PRE-SEA EDUCATION

NAME OF SCHOOL OR ACADEMY

DEPARTMENT

FROM

(YEAR)

TO

(YEAR)

SEVASTOPOL NATIONAL TECHNICAL UNIVERSITY




2004

2010















I hereby affirm that all the information provided by me in this form is true and correct to the best of knowledge.


Date of signing Signature

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