APPLICATION FORM

Last name:

/

Goncharenko

/

Rank:

/

Third Officer

First name:

/

Oleksandr

/

Position required:

/

AА

Date of birth

/

Place of birth

/

Citizenship

/

Marital status:

/

Married

10.12.1975

/

Ukraine

/

Ukrainian

/

Next of kin:

/

Goncharenko Oksana, wife

Address: / 36 Mendeleeva Str., Izmail, Odessa reg. /

Address:

Mobile: /

The same

+38050199 42 08

Tel:

/ /

Mob:

/

+38050199 42 07

E-Mail:

/

Height (sm.):

/

192

/

Overalls:

/

54

Eyes:

/

Brown

/

Hair:

/

Black

/

Weight (kg.):

/

80

/

Shoes:

/

44

MARITIME EDUCATION

Establishment /Name of institution / Qualifications / Date of attended
Nikolayev Center of Training of Seafarers /

Ship’s sailor

/ 2007
Kiev Marine College / Navigator / 2011

PERSONAL DOCUMENTS

Description / Number / Issued / Expired / Place of issue
Civil Passport /

KE 543291

/ 27.01.1997 / Permanent / B.-Dnestrovskiy
Tourist Passport / EA 139576 / 17.08.2007 / 17.08.2017 / Izmail
Seaman's Identification Card / AB 466450 / 06.12.2011 / 06.12.2016 / Izmail
US C1/D VISA / No

PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY

Certificate Name / Number / Issued / Expired / Place of issue
Certificate of Competency / 00468/2012/01 / 26.04.2012 / Permanent / Izmail
Endorsement to certificate / 00468/2012/01 / 26.04.2012 / 31.12.2016 / Izmail
Rank / Officer in charge of a navigation watch on ships 500 GRT or more

MARINE COURSES

Description

/ Number / Issued / Expired / Place of issue
STCW 78/95 A-VI/1(basic safety) / 3/239/12 / 26.03.2012 / 31.12.2016 / Illichivsk
STCW 78/95 A-VI/2(survival craft) / 3/185/12 / 26.03.2012 / 26.03.2017 / Illichivsk
STCW 78/95 A-VI/3(fire fighting) / 3/103/12 / 26.03.2012 / 26.03.2017 / Illichivsk
STCW 78/95 A-VI/4(medical care) / 3/070/12 / 26.03.2012 / 26.03.2017 / Illichivsk
Ships carrying danger/hazard cargo / 3/129/12 / 26.03.2012 / 26.03.2017 / Illichivsk
ARPA/ RADAR / 3/014/12 / 26.03.2012 / 26.03.2017 / Illichivsk
Ship Handling Arrangements
Certificates GMDSS / 00091/2012/01 / 24.04.2012 / Permanent / Izmail
GMDSS Endorsement / 00091/2012/01 / 24.04.2012 / 31.12.2016 / Izmail
Electrical & electronic maintenance
Designate Security Duties of Seafarers / 1790 / 27.01.2014 / 27.01.2019 / Mariupol
Ship Security Officer (ISPS Code) / 20/02 / 07.02.2013 / 07.02.2018 / Odessa
ECDIS / 5628/MPS / 25.11.2015 / 25.11.2020 / Izmail
Level of language / Eng. / Ger. / Advanced / Intermediate / Elementary / Beginner

HEALTH CERTIFICATES

Name of the Certificate / Issued / Expired / Place of issue
Physical Examination Certificate
Drug/Alcohol Test Report
Yellow Fever / 26.05.2009 / 26.05.2019 / Odessa
Cholera
Typhoid
Have you ever signed off a ship due to medical reasons? / Yes / No

SEA SERVICES (last five years)

Company name / Rank / Vessel’s
name / Flag / Type / GRT / DWT / Engine type / BHP/
KW / From / To
Ship Dream El Helm Shipping CO SAE / 3- rd. Off / NAVIGATOR B / Tuvalu / Bulk Carrier / 16 725 / 28 470 / MITSUI / 13.01.15 / 17.08.15
TANAIS Shipping LTD / 3- rd. Off. / TANAIS EXPRESS / Belize / Bulk Carrier / 14 889 / 25 698 / HITACHI B&W / 05.02.14 / 18.09.14
TANAIS Shipping LTD / AB / TANAIS EXPRESS / Belize / Bulk Carrier / 14 889 / 25 698 / HITACHI B&W / 24.11.13 / 05.02.14
TANAIS Shipping LTD / AB / TANAIS LEADER / Belize / Bulk Carrier / 16 605 / 27 622 / MITSUI / 08.02.13 / 10.10.13
UNISHIP / AB / BLANKENESE / Malta / Gen. Cargo / 4200 / WARTSILA / 28.03.11 / 24.10.11
UNISHIP / AB / KALIPSO / St. Vinc. / Gen. Cargo / 6200 / WARTSILA / 10.04.10 / 31.10.10
UNISHIP / AB / MEROPA / Malta / Gen. Cargo / 2950 / WARTSILA / 18.09.09 / 11.03.10

_.11.2015_ _Goncharenko_

(Date) (Signature)