PERSONAL DATA / APPLICATION FORM
Position applied for: motorman License hold: 3 rd class engineer Date Available: ready now
Family Name: Stepanenko / Name: Yevgen / Father's name: Vladimirovich
Date of birth: 18.10.1981 / Place of birth: Ukraine Kerch / Nationality: Ukrainian / Marital status:married
Address: Ukraine Kerch O.Kоshevogo str. 30-29
……………………………………………………………………………….. / Nearest Airport Simferopol..…………………………………………..
…………………………………………………………… / Home phone: 0656173914
Mobile phone: 0506478429
Mail:
Next of kin and relationship: Stepsnenko Anna - wife / Children (name & DOB):Stepanenko Radion
Next of kin’s address: Budeniogo str. 40-40 / Next of kin tel:0502562529
Inter. P’port No: EM 136471 / Issued: 04.06.2007 / Valid: 04.06.2017 / Place of issue: : KERCH
Seaman's book No: AB 394353 / Issued: 01.01.2012 / Valid: 01.01.2017 / Place of issue: PORT KERCH
Civil P’port No: EC 689395 / Issued: 14.08.1998 / Date of issue: KERCH
USA visa No: / Issued: / Valid: / Place of issue:

SEA GOING EXPERIENCE FOR THE LAST 7 YEARS

(MOST RECENT VESSEL LAST)

Name of vessel / Year of built / Company Owner /
Ship Manager / Flag / Type of vessel / DWT /
TEU / ME type /
Model / BHP / Rank / From
DD/MM/YYYY / To
DD/MM/YYYY
KATAN / 1978 / Sonit Peche / GUINEE / Refregerator / 2557 / NVD / 2x1706 / motorman / 25.07.2007 / 15.06.2008
KORALAS / 1983 / Baltlanta / Lithuania / Fish Factory Ship / 3879 / SUlZER / 2854 / motorman / 20.11.2008 / 28.01.2009
KOUBIA / 1985 / Sonit Peche / GUINEE / Fish Factory Ship / 1895 / MAK 6m20 / 2x1020 / Motorman-fitter / 03.07.2009 / 07.01.2010
KOUBIA / 1985 / Sonit Peche / GUINEE / Fish Factory Ship / 1895 / MAK 6m20 / 2x1020 / Motorman-fitter / 29.06.2010 / 10.01.2011
GRAND VISION / 1991 / Golden port / Monrovia / Container / 36627 / SULZER-7RTA / 45220 / wiper / 08.10.2011 / 19.12.2011
Name of Maritime Institution attended / Address of institution / From / To / Degree of Diploma
Kherson secondary marine school of fishing industry / Ukraine, Kherson city / 28.10.2009 / 02.06.2011 / Junior specialist of engineering
STCW Certificates / Number / Issued / Valid / Place of issue / STCW Certificates / Number / Issued / Valid / Place of issue
Certificate of competency / 00514/2011/11 / 28.07.2011 / PORT KHERSON / GMDSS Endorsement
Endorsement / 00514/2011/11 / 28.07.2011 / 01.06.2016 / PORT KHERSON / Radar observer
Personal safety / 18164/2011/42/01 / 01.06.2011 / 01.06.2016 / NIKOLAEV / ARPA
Advanced fire fighting / 09693/2011/42/04 / 01.06.2011 / 01.06.2016 / NIKOLAEV / AIS course
Prof. in survival craft / 15685/2011/42/02 / 01.06.2011 / 01.06.2016 / NIKOLAEV / BTM course
Medical first aid / 05707/2011/42/05 / 01.06.2011 / 01.06.2016 / NIKOLAEV / ECDIS course
Medical care / Security officer (ISPS)
Dangerous cargo / 11542/2011/42/20 / 01.06.2011 / 01.06.2016 / NIKOLAEV / Safety officer (ISM)
Oil Tanker Familiarization / 04184/2011/42/10 / 01.06.2011 / 01.06.2016 / NIKOLAEV
Medical examination / Issued: 07.06.2011 / Valid: 07.06.2012 / Weight, kg: 95 / Height, cm: 180
Drug & alcohol test / Issued: 07.06.2011 / Valid: 07.06.2012 / Eyes: green / Hair: bionde
Yellow fever / Issued: 19.06.2007 / Valid: 19.06.2017 / Overall size: 56 / Safety shoes: 42-43
Another States Seamen’s Books / Rank / Document No / Issued / Valid / Another States Certificates of competency / Rank / Document No / Issued / Valid
Liberia / Liberia
Panama / Panama

Please complete addresses of your previous employers for references

Company / Tel / Company / Tel
Address / Address

CD-P03A1

Application Form Appendix 1 Second Issue Revision 1 Page 1 of 2