Previous Sea Experience (For Last 5 Years)

Pulsar Service Marine agency

54017, Ukraine, Nikolaev, pr. LENINA, 70/18. phone +380994484050 Phone/fax: +38 (0512) 47-45-60. Skype: pulsar-servicemk E-mail: [email protected] License: AB 487508 issued 12.01.10

Position applied for: Date available: SURNAME NAME FATHER'S NAME Date and place of birth Address,  City: Street/Ave: Personal civil code: House: Apt: Mob : Height: Weight: Overall: Shoes: Eyes: Hair: E-Mail : ICQ : SKYPE : Yellow Fever valid Title of the document № Date place of issue Valid up Seaman's book National passport Foreign passport Cyprus passport Panama passport Other passport Certificate of competency Rank Deep sea navigator Endorsement GMDSS operator Endorsement Basic Safety Training STCW-95 Advanced Training in Fire Fighting Medical Emergency - First aid Proficiency in Survival craft Medical Care on Board Ship Radar Navigation-Managemen Level Ship Handling Arrangements Ships Security Officer A Ships Security Officer A, B Electronic Chart Display And Information System Oil Tanker Familiarition Dangerous and Hazardous Substan. Other foreign languages Second (relative) specialty Lathe machine skills Welding skills PC knowledge Certificate Valid USA visa

PREVIOUS SEA EXPERIENCE (FOR LAST 5 YEARS): NAME OF TYPE RANK DWT FROM TILL COMPANY THE VESSEL VESSEL YEAR TYPE OF FLAG OF HP THE MAIN BUILD ENGINE

MARINE EDUCATION RECEIVED NAME OF SCHOOL FROM TILL TYPE OF DEGREE RECEIVED

ADDITIONAL INFORMATION Marital status: Religion: Wife (Name, First name, Date and place of birth) Children under the age of 18 (names, date of birth )

Next of kin (Name, date of birth, address, phone #) LEVEL ENGLISH TEST English language knowledge Excellent Good Satisfactory Poor Computer proficiency Excellent Good Satisfactory Poor

I, undersigned, confirm all above information to be true and correct to my best knowledge:

Signature of the Applicant ______