Application Form
Section 1 / Position
Position Applied for
/ Master
Lowest Position Acceptable
Date of Availability / 08 / 01/2013 MUST Enter a date and in dd/mm/yyyy
Section 2 / Personal Details
Family name / Surname / Gordienko
First Name / Given Name / Pavel
Date & Place of Birth / Date - 03.03.1970 Place- Novograd-Volynskiy/USSR/
Nationality / Russian
Permanent Address / Karandina str.,89 Astrakhan, Russia
Present Address / The same
Present Contact Number / +7903 349 06 93
Fax Number
Mobile Number / +7903 349 06 93/home/ mob UAE:+971-566-192-689
Email Address /
Nearest Airport / Astrakhan, alternative- Baku ,Moscow/Sheremetyevo/
Section 3 / Passport, VISA & Seaman book ( Discharge book )
Passport -Country of Issue / RUSSIAN / US Visa - Type / n/a
Passport -Date Issued / 07.09.09 / US VISA Expires
Passport -Place Issued / ASTRAKHAN / Seafarer’s ID no / RUS 0066647
Passport Number / 70 4025101 / Seafarer’s ID Issue Date / 28.04.2011
Passport -Expires / 07.09.2014 / Seaman Book Expiry Date (if any) / 27.04.2016
Section 4 / Next of Kin wife
Full Name / Relationship / Gordienko Tatyana
Address / The same
Contact Numbers / Mob. +7906 45 94 764
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Section 5 Highest Certificate of Competency / Licence Held ( also list Flag State Endorsements)
Class / Grade / Issuing Country / Certificate No. / Date Issued / Expires / Details of Limitations
Master II/2 / Russia / 2030101675 / 23.05.2006 / 17.07.2014 / None
ALSO ENTER ABOVE DETAILS OF ANY OTHER FLAG STATE CERTIFICATES HELD: INDONEZIAN,SINGAPORE,COMMOROS ENDORSEMENTS UN TILL 17.07.2014
Section 6 Dangerous Cargo Endorsements
Petroleum…………….
Liquified Gas………...
Liquid Chemicals……. / Certificate No. / Date Issued / Expires / Details of Limitations/ Grade
n/a
n/a
n/a
Section 7 Courses Attended and Certificates Obtained
Name of Course / Certificate / Institute / Place / Date / Cert No / Expires
BasicSea Survival / Maritime State Academy of Admiral Ushakov / Astrakhan / 17.07.09 / 212362 / 17.07.14
Proficiency in Survival Craft / Maritime State Academy of Admiral Ushakov / Astrakhan / 25.07.09 / 181443 / 25.07.14
Personal safety & Social Responsibility / Same as above / Same as above / 17.07.09 / 212362 / 17.07.14
Fire Fighting / Same as above / Same as above / 17.07.09 / 212362 / 17.07.14
Advanced Fire Fighting / Same as above / Same as above / 25.07.09 / 076596 / 25.07.14
Medical & First Aid / Same as above / Same as above / 17.07.09 / 082572 / 17.07.14
Ship Captains Medical Course
GMDSS + ENDORSEMENT / Same as above / Same as above / 17.07.09 / 0078453/
2032302005 / 17.07.14
Ship Security Officers Course (SSO)
(ISPS) / Maritime State Academy of Admiral Ushakov / Astrakhan / 23.01.10 / 034859 / 23.01.15
Personal Survival Techniques / Same as above / Same as above / 17.07.09 / 212362 / 17.07.14
Medical Certificate / HEALTH Certificate / Clinic III international FGU”UOMC Roszdrava” / 25.06.12 / n/a / 25.06.13
UKOOA / n/a
Medical Care / Academy of Admiral Ushakov / Astrakhan / 17.07.09 / 082572 / 17.07.14
Radar Observer / The same / The same / 17.07.09 / 0124243 / 17.07.14
Radar Simulator / The same / The same / 17.07.09 / 0124243 / 17.07.14
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Section 7 (continued) Courses Attended and Certificates Obtained
Please enter below any other certificates held or courses done, ie offshore, DP certs etc or Any other not already mentioned
Name of Course / Certificate / Institute / Place / Date / Cert No / Expires
Initial Standby vessel crews training ( ITSO )
HUET / EBS
CAA (Civil Aviation Authorities – Helicopter)
Proficiency in RESCUE BOATS / Astrakhan / 25.07.09 / 181443 / 25.07.14
Proficiency in RESCUE CRAFTS / Astrakhan / 25.07.09 / 181443 / 25.07.14
Advanced Medical Aid
Electronic chart Display andInformation System course
YELLOW FEVER / Krasnodar / 20.01.10 / 20.01.20
BOSIET
MARLIN’s English Test / Astrakhan Technical University / 11.04.2011- 100%
DP Maintenance Courses
DP Maintenance Courses
Dynamic Positioning Induction Course
Dynamic Positioning Simulator Course
Dynamic Positioning Operators CERTIFICATE / Full or Limited
Dynamic Positioning Log book Details
Section 8 Hours done with various DP system
SYSTEM DETAILS / Approx Hours as SDPO / Senior ETO / Senior Engineer / Approx Hours as JDPO / Junior ETO / Junior Engineer
APPROXIMATE Total DP Hours in Various Operations
SAT DIVING / CABLE LAYING
AIR DIVING / SURVEY
ROV / PIPE LAYING
WELL STIM / ACTIVATION / INTERVENTION / DRILL SHIP / SEMI SUB
AHTS / PSV
FPSO / SHUTTLE TANKER
ACCO / GANGWAY / CONSTRUCTION / HL
MATRESSING / ROCK DUMPING / TRENCHING
CORE SAMPLING
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Section 9 Medical History
YES / NO
Have you ever signed off a ship due medical reason ?
/ no
Have you undergone any medical operations in past ?
/ no
Have you consulted a doctor during the past 12 months for an illness / Accident / no
Do you have any health or disability problem now ?? / no
If answer to any of above is YES then give further details below or on a separate sheet
NOTE : All our clients have STRICT Alcohol and Drug Policy, Which means ZERO TOLERENCE for alcohol and drugs
Section 10 General
Yes / No
Have you ever been the subject of a court of enquiry or involved in a maritime accident / No
Have you ever had a professional licence suspended or revoked / no
If yes to any of above then please full details below or on separate sheet of paper no
Section 11 References (Last Two Recent Employers)
Name of company
/ Kaspiiskiy Buksir
Name Person to be contacted
/ HR Manager: Marina Vladimirova

Address Contact Caspiisky Buksir

Tel 1: +7 7292 470 335
Tel 2: +7 7292 470 336
Fax: +7 7292 470 337
By Post
Caspiisky Buksir
Mcr 7, Bldg 4
Entrance on main road,
Opposite Volna
Aktau 130000
Republic of Kazakhstan / Top of Form
Bottom of Form
E:mail:
VALENTINE MARITIME GULF LCC
Name Person to be contacted
/ HR MANAGER/ Mohammad Zakir
Address / P.O.Box 45877,Abu Dhabi, UAE
Tel No / +97125555868 / Fax / +97125559991
Email /
Name of company
/ Caspian Services Group Ltd
Name Person to be contacted
/ Arran Watson/ branch director
Address / 523office,5-th floor,14/61’’Aktau business centre, Aktau 130000,Kazakhstan
Tel No / +7701 7171364 / Fax / +7 7292 470014
Email /
Section 12 Any other information, you wish to add in support of your application
Section 13 Declaration
I hereby declare that the above particulars are true and I authorize you to contact the referees listed above
And confirm that All my certificates / Licences are Authentic
Signed ………Gordienko Pavel Date………06.12.2012…………..
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Section 14 Record of Sea Service (All Dates to be entered as dd/mm/yy)
Please give full record of sea service STARTING FROM LAST VESSEL FIRST
VESSEL / COMPANY / Type of Vessel
And Type of operation in case of DP vessels / DWTor GRT
(please delete as reqd) / Type of Engines
Or DP System / BHP / RANK / Sign on DATE / Sign off DATE
dd / mm / yy dd / mm / yy
Jean Charcot / Brasbunker Co
Brazil / Ocean geographically
Research vessel / 2141t / Mans / 3600 / Master / 29.08.2012 / 08.11.2012
TB PEARLY / Thong Yong Marine / TUG / 320t / Cummins / 3200 / Master / 30.12.11 / 31.01.12
OHSU / Thong Yong Marine / SRV / 294t / Cummins / 2400 / Master / 01.12.11 / 29.12.11
OHSU / Thong Yong Marine / SRV / 294t / Cummins / 2400 / Master / 17.08.11 / 23.10.11
Afon Cefni / Kaspiiskiy Buksir / AHTS / 210 t / Cummins / 2000 / Master / 24.04.11 / 01.08.11
Valentine-2 / Valentine Maritime Gulf LCC / AHTS / GRT/494 / Yanmar / 4000 / Master / 01.05.10 / 01.08.10
Sara Maatje-IX / Caspian Services Group ltd / AHTS / 300t / Mitsubishi / 1837 / Master / 18.01.2008 / 07.07.2009
CS Carmen / Caspian Services Group ltd / AHT / 200 T / Caterpillars / 1000 / Master / 01.01.2007 / 05.12.2007
CS Marina / Caspian Services Group ltd / AHT / 200 T / Caterpillars / 1000 / Master / 26.08.2006 / 05.12.2006
Afon Cefni / Silverbern co / AHTS / 210 t / Cummins / 2000 / Ch.mate / 01.06.2006 / 19.08.2006
Grigoriy Nosov / Sovfraht / General cargo / 3660t / n/a / 2200 / Ch.mate / 05.11.2005 / 07.03.2006
Grigoriy Nosov / Sovfraht / General cargo / 3660t / n/a / 2400 / Ch.mate / 23.04.2005 / 08.07.2005
Rasul Gamzatov / Commercial
Sea-port of Makhachkala / General cargo / 6200t / SKL / 2640 / Ch.mate / 01.12.2003 / 18.08.2004
Dyurso / Commercial
Sea-port of Makhachkala / General cargo / 6200t / SKL / 2640 / Ch.mate / 16.12.2002 / 31.05.2003
Alex-II / AGMOS / General cargo / 1200t / n/a / 1100 / Ch.mate / 19.01.2002 / 26.07.2002
Vladimir Pravik / Commercial
Sea-port of Makhachkala / tanker / 7080t / n/a / 2740 / Ch.mate / 18.06.2001 / 21.11.2001
Ali Aliev / Commercial
Sea-port of Makhachkala / General cargo / 4200t / n/a / 2400 / Ch.mate / 01.12.2000 / 17.03.2001
Ali Aliev / Commercial
Sea-port of Makhachkala / General cargo / 4200t / n/a / 2400 / 2 –nd mate / 18.07.2000 / 01.12.2000
Dagestan / Commercial
Sea-port of Makhachkala / General cargo / 4200t / n/a / 2400 / 2 –nd mate / 07.01.1999 / 07.01.2000
Dagestan / Commercial
Sea-port of Makhachkala / General cargo / 4200t / n/a / 2400 / 2 –nd mate / 09.06.1998 / 23.10.1998
Volgo-Balt-13 / Kaspmorput co ltd / General cargo / 2700t / n/a / 1320 / 2 –nd mate / 23.11.96 / 13.04.1998
RDOS ‘’Trusovskiy” / Kasprubholodflot / Fishing / 670t / n/a / 1100 / 3-d mate / 05.11.1995 / 05.11.1996
Volgoneft-164 / Volgotanker,co / tanker / 5500t / n/a / 2400 / 3-d mate / 16.03.1994 / 15.07.1995
Type of Engines :: for engineers only, DPOs to Mark DP System BHP : for Engineers and AHTS / TUG Masters & Officers Page 5 + 6 of 7
ADDITIONAL INFORMATION SHEET
VESSEL TYPE YOU ARE INTERESTED IN (please list in order of priority)
  1. Push-tug-supply vessel

  1. AHTS

  1. MLP

  1. Tug

5.
MAXIMUM ACCEPTABLE TRIP LENGTH (Please indicate below)
2/two/ month
MINIMUM SALARY or DAY RATE EXPECTATION (please quote below in GBP£ (for British Nationals) or in US$ (for NON-UK personnel)
Amount to enter below to be consolidated of any leave pay ( ie, inclusive of leave pay), Please enter MINIMUM in order we can forward your CV for all offering above that ( please enter Only realistic figure )
420 usd per day/ i think it’s a realistic
Languages Spoken / Written / Understood (1-poor 5-Fluent)
Spoken / Written / Understood
ENGLISH / 4 / 4 / 4
DRUG & ALCOHOL POLICY
ALL Our Clients have very strict NO DRUG and ALCOHOL POLICY, Which is required to be complied with at all times, which means “””ZERO TOLERENCE on ALCOHOL & DRUG”””
Your body must NOT have any ALCOHOL or DRUG substances from the time you board your flight or commence your travel to join vessel, and Must remain so Until you have completed full contract and returned to your home Airport / Town
If during the said period you are found under the influence of DRUG or ALCOHOL then ALL EXPENCES incurred which will include all your travel and recruiting costs, And your relief’s Travel and recruiting costs, And Any other costs whatsoever incurred due to your NON-COMPLIANCE will be deducted from your salary, Which will include but not limited to “damage to vessel her equipments and machineries, loss of charter, and any other costs Directly or indirectly connected with your NON-COMPLIANCE
CONFIRM ACCEPTANCE OF ABOVE POLICY
FOLLOWING DOCUMENTS COPIES MUST BE SENT TO US
Licence or Certificate of competency, Any tanker endorsements, GMDSS showing expiry date in case of Deck Officers, Medical Fitness / Examination Certificate, Passport Main page, Seaman book or Discharge book Main pages, In case of DPO – DPO Cert, DP LOG Pages
FOLLOWING ADDITIONAL DOCUMENTS COPIES MAY ALSO BE REQUIRED
All short courses certificates ( STCW95 ), SSO certificate, Last 3-5 years ships entries in Discharge book or Seaman book, Certificate of Equivelant Competency from other flag states

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