Seafarer's Application Form - Personal Data

SEAFARER'S APPLICATION FORM - PERSONAL DATA

PERSONAL INFORMATION
Family Name / RUSEV / First Name (s) / RUMEN
Birth Date / 30.08.1970 / Birth Place / VARNA
Nationality / BULGARIAN / Religion / CRISTIAN
Marital Status / MARRIED / No. of Children / NO
Height (cm) / 171 / Weight (kg) / 84
Nearest Airport / VARNA / Colour of eyes & hair / BROWN
ADDRESS (include telephone country & area codes, advise also secondary or contact addresses if any)
Street & Nr. / TOPRA HISAR 16 / Email Address /
Location / VARNA / Mobile Phone / 0882946935
City / VARNA / Residence Phone
State, Country / BULGARIA / Fax
Postal (ZIP) Code / 9000 / P.O. Box (if any)
NEXT OF KIN INFORMATION (person to contact in case of emergency & insurance beneficiary)
Full Name / ALBENA HARI RUSEVA / Relationship / WIFE
Nationality / BULGARIAN / Phone / 0885221861
Street & Nr. / TOPRA HISAR 16 / Email Address
Location / VARNA / Mobile Phone / 0878693992
City / VARNA / Residence Phone
State, Country / BULGARIA / Fax
Postal (ZIP) Code / 9000 / P.O. Box (if any)
REMARKS
Requested Rank / CH.COOK / Availability Date / 01.10.2013
Lower rank – acceptance (Y/N) / Conditions (salary, trading area, etc.) to accept lower rank
Prefer. Vessel Type / g.cargo,tank.cont.bulkcar. / Minimum Salary / 1500euro
English Language Skills / Exelent for the position
Other Foreign Languages / russian
ProfessionalSchool / Academy - Name & Period (From - To) / Tehnical school ANTON IVANOV
Foreign Crew Experience (specify nationalities) / Russians,philippinians,arabians,indians and more
Further Remarks
I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge.
Date:14.11.13 / Signature:

SEAFARER'S APPLICATION FORM - LIST OF DOCUMENTS

A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES
Document Name (Description) / Document Number / Issue Place / Issue Date / Exp. Date
Passport / 380224511 / VARNA / 02.07.2010 / 02.07.2015
Seaman's Book (national) / 500801461 / VARNA / 06.07.2010 / 02.07.2015
Seaman's Discharge Book
Visa –US / C1/D / 20121924370001 / SOFIA / 11.06.2012 / 10.06.2022
Medical Examination Report
Drug & Alcohol Test
Vaccination against Yellow Fever / 5820 / TARANTO / 29.11.2005 / 29.11.2015
Other FlagState Passports
B. CERTIFICATES OF COMPETENCY & ENDORSEMENTS, COURSE CERTIFICATES
Document Name (Description) / Document Number / Issue Place / Issue Date / Exp. Date
BGR Certificate of Competency / 1101 / VARNA / 28.08.2013 / unlimited
Endorsement of National CoC
Personal Survival Techniques / 1224/2307 / VARNA / 31.07.2013 / 30.07.2018
Fire Prevention & Fire Fighting / 1224/2307 / VARNA / 31.07.2013 / 30.07.2018
Elementary First Aid / 1224/2307 / VARNA / 31.07.2013 / 30.07.2018
Personal Safety & Social Resp. / 1224/2307 / VARNA / 31.07.2013 / 30.07.2018
Proficiency in Survival Craft
Advance Fire Fighting
Medical First Aid
Medical Care on Board
Ship Security Officer/Team
HAZMAT
ARPA
Radar
Pass Ship Crowd Management
Pass Ship Crisis Management
Pass Ship Familiarization
Pass Ship Safety Training
Tanker Familiarization / 1006 / VARNA / 04.03.2002 / UNLIMITED
Oil Tanker – Advanced training
Chemical Tanker - Advanced training
Gas Tanker - Advanced training
Skipper of Seagoing Vessel up to 20gt
ECDIS / OB
Bridge Team Management
Liquid Cargo and Ballast
Handling Simulator
Prof.for seaf.with design.sec.dutie / 38206 / varna / 11.12.2013 / UNLIMITE

SEAFARER'S APPLICATION FORM - SEA SERVICE (LAST 10 YEARS)

First name (s):Family name (s):Date of Birth:

Vessel’s Name / Type / Rank / From / To / Vesssel’s IMO № / GT / DWT / Engine builders / Engine type/ kW / Flag / Employer / Manning agent
(company to contact for reference)
EVERGLADES / Cr.oil / Ch.cook / 17.02.13 / 25.07.13 / 62775 / 120000 / malta / v-ships bulgaria
As suwayq / vlcc / Ch.cook / 13.07.12 / 13.01.13 / 318000 / s.korea / malta / v-ships bulgaria
Santa rossa / bulk / cook / 22.08.11 / 03.03.12 / 9978 / 12000 / slovakia / Ahileus manning
Setubal castle / bulk / cook / 26.07.10 / 24.04.11 / 18455 / malta / B - navy
Kay-l / g.carg. / cook / 15.01.10 / 27.06.10 / 1000
mina / g.carg / cook / 23.02.08 / 25.07.08 / 1961 / malta / Vega manning
Sea dog / Suppl. / cook / 21.11.07 / 20.11.07 / malta / Vega manning
Santa milagria / Bulk. / Stew. / 11.05.07 / 12.10.07 / 76813 / cuprus / Vega manning
Sabrata star / g.carg. / Stew. / 14.11.05 / 12.02.06 / 5755 / cym / b-navy