OSA_Application

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..SEAFARER’S APPLICATION FORM
Name in full (First, Middle, Last) :
Vadim
Rank :
PHOTO
Date & place of birth:
08.09.1988 Ukrain
Nationality:
Ukrain
Single
MarriedDivorced
Widower
Nearest Airport: Obessa
Permanent Address:
Obessa
Tel: 361325
Mob:0935821706
e-mail:broslavec.vadim@mail.ru skype:
Next of kin (surname, name, date of birth):
Maze Skarlat lilia
Relationship:
Address: Obessa
Mob: 0672883829
Children (surname, name, date of birth):
1.no
2.
3.
Colour of hair/eyes: dlack/broun
Height:
175
Weight:
70
Shoes size:42
Clothes size:48-50
Educational History (name of educational institution, dates of entry / graduation and degree):
YELLOW FEVER VACCINATION:
Country of issue
Number:
Date issued:
Place issued:
Expiry Date:
Remarks
kostromin
7794
28.07.15
Obessa.vivameb
28.07.25


Marshall Islands
OTHER CERTIFICATES AND ENDORSEMENT INFORMATION:
Certificate/Endorsement
STCW Regulation No
Number
Date issued:
Place issued:
Expiry Date:
GMDSS (for Deck Officers)
A-IV/2
GOC or ROC
ARPA / Radar
A-II/1, A-II/2
ECDIS
B-I/12
Ship Security Officer
A-VI/6-5
ISPS
A-VI/6-2
Basic Safety Training
A-VI/1
First Aid / Medical care onboard
A-VI/4-1 // A-VI/4-2
Survival craft & rescue boats
A-VI/2-1
Advanced Fire Fighting
A-VI/3
SEAMAN’S & PASSPORT BOOK INFORMATION:
National Seaman’s Book no
Place & Date Issued:
Expiry Date:
Travel Passport
Place & Date Issued:
Expiry Date:
Obessa
23.01.15
23.0125
Marshall Islands Seaman’s Book
Place & Date Issued:
Expiry Date:
Other Seaman’s Book
Place & Date Issued:
Expiry Date:
Ilyichevsk
01.0715/01.0720
VISA INFORMATION:
Visa:
Type:
Valid Until:
Remarks:
USA visa
no
Schengen
no
LANGUAGE INFORMATION:
Good
Satisfactory
Poor
Remarks
English
Other language
Availability for Service:
USAM MARITIME
RECORDS OF PREVIOUS SEA SERVICE
Vessel’s Name
Flag
IMO Number
DWT /
Type and Model of M.E., kW
Vessel’s
Type / Deck Cranes
Rank
From
(date-month-year)
To
(date-month-year)
Months
Company
(Shipowner /Technical Manager/ Crewing Agency)
I hereby provide that all the information provided by me in this form is true and correct to the best of my knowledge.
Signed by Seaman:
Date:
References:
Company (Crewing or Shipowner) / Contact person (Superintendent, Manager, Captain, Chief Engineer or other person/ Telephone number ):
________________________________________________________________________________________________________________________
Подтверждаю, что мои персональные данные, указанные в анкете, являются общедоступными.
I hereby confirm that my personal details contained herein are for public use.
Signature of Seafarer (подпись Mоряка): _________________ Date (дата): _31.08_2015_____________________________
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