Капитан судна

Описание

APPLICANT’S PERSONAL DATA



POSITION OR RANK:
FAMILY NAME lisitsa CITIZENSHIP: Russian
[pic]
FIRST NAME gennady ADDRESS (full mail style): 53 M.Zhelezniaka str. Saint
Petersburg, Russia
FATHER’S NAME DENISOVICH
DATE OF BIRTH 24.02.1957
PLACE OF BIRTH Minsk region Belarus Nearest Airport: Pulkovo
E-MAIL gennadyden@mail.ru HOME PHONE:
OTHER CONTACTS +7 981 124 6406 MOBILE PH.: +7 981 124 64 06
MARITAL STATUS Married NEXT OF KIN INFORMATION:
WIFE’S FAMILY NAME lisitsa RELATION: Wife
WIFE’SFIRST NAME IRINA
WIFE’S FATHER’S NAME ALEXANDROVNA
DATE OF BIRTH 11.09.1964
ADDRESS (full style): index
CONTACT PHONE: +7 911 835 8788


CHILDREN’S LAST/FIRST NAME (UNDER 18) : CHILDREN’S DATE OF BIRTH : Number of kids




CLOTHES SIZE CLOTHES SIZE
Maritime Colledge Saint Petersburg 01.09.2000 02.07.2003 Technician-navigator

PASSPORT / SBK ISSUED BY NO. ISSUE DATE VALID TILL
SEAFARER’S INDENTITY DOCUMENT S-t Petersburg FSI harbor RUS 0405185 23.04.2018 23.04.2023
RUSSIAN SEAMAN’S BOOK S-t Petersburg FSI harbor MK 0158776 08.04.2013
TRAVELLING PASSPORT S-t Petersburg FMS 78039 72 3708945 22.03.2013 22.03,2023
GRADE NO. ISSUE DATE VALID TILL
NATIONAL LICENCE: Master (no limitations 1010109183 08.08.2016 17.06.2021
ENDORSM : OI L Chem LPG
GMDSS: Gen. Oper. X Restr Oper. TC Marsatar Spb 0053843 11.12.2007 17.06.2021
GMDSS ENDORSEMENT TC Marstar Spb 0053843 08.08.2016 17.06.2021

CERTIFICATE STCW CODE NO ISSUED VALID TILL
BASIC SAFETY TRAINING STCW ‘95 A-VI/1-4 0485292 27.07.2016 27.07.2021
ADVANCED FIRE FIGHTING : A-VI/3 0485680 24.06.2016 24.06.2021
PROFICIENCY IN SURVIVAL CRAFT, RESCUE B. A-VI/2-1 0486322 04.07.2016 04.07.2021
MEDICAL EMERGENCY FIRST AID A-VI/4-1 0486818 13.07.2016 13.07.2021
MEDICAL CARE CERTIF. A-VI/4-2 1633 15.07.2016 15.07.2021
SECURITY DUTIES / AWARNESS A-VI/6-2
SHIP SECURITY OFFICER A-VI/5 0487819 17.06.2016 17.06.2021
ECDIS B-I/12, AII/1-3 0382061 22.07.2016 22.07.2021
RADAR OBSERVERVATION AND PLOTTING A-I/12, B-I/12 0381844 21.06.2016 21.06.2021
ARPA (AUTOMATIC RADAR PLOTTING AIDS) A-I/12, B-I/12 0381933 23.06.2016 23.06.2021
HAZMAT B-V/b, B-V/c 2511 20.04.2018 20.04.2023
HAZMAT (USA-TITLE 49)

BASIC TRAINING FOR OIL AND CHEMICAL TANKERS A-V/1-1
ADVANCE TRAINING FOR OIL TANKERS. A-V/1-1
ADVANCE TRAINING FOR CHEMICAL TANKERS A-V/1-1
BASIC TRAINING FOR LIQUID GAS TANKER A-V/1-2
ADVANCE TRAINING FOR LIQUID GAS TANKER A-V/1-2




HEALTH CERTIFICATE Issued by Marine Medic.centerSpb Date of issue 22.04.2019 Valid till 22.04.2020
YELLOW FEVER Issued by Med center Spb Date of issue 24.11.2010 Valid till 24.11.2020


OTHER DOCUMENTS ISSUED BY NO ISSUED VALID
BTM (B-VIII-2) / BRM
SH (Ship’s Handling & Maneuvering)
ECDIS SPECIFIC TRAINING


ENGLISH KNOWLEDGE (tick) EXCELLENT X GOOD
USA
SCHENGEN 004828686 Saint Petersburg/Russia 03.08.2016 02.08.2019
MCV (Australian Maritime Crew Visa)



FLAGS DOCUMENTS (INSERT FLAG NAME IN GREY BOX; NIS, LIBERIA, CYPRUS, PANAMA etc)


GRADE NBR
INOK-TM +7 921 969 1084 Ksenia Vadimovna
Feederlines B.V. +31 50-588-7777 Robert Bronts

С автоматизированной обработкой моих персональных данных, указанных в анкете, их передачей третьим лицам (включая трансграничную) и хранением в целях трудоустройства в соответствии с Федеральным законом РФ N 152-Ф3 согласен, что подтверждаю заполнением и отправкой настоящей Анкеты - Application Form. Также подтверждаю, что мои персональные данные являются общедоступными.

DATE: 03.02.2017 SIGNATURE OF SEAMAN:


FOR OFFICE USE ONLY: