APPLICATION FORM

APPLICATION FORM

PERSONAL DATA / APPLICATION FORM Position applied for __ CH. MATE / MASTER__ License hold ___DEEP SEA CAPTAIN____ Date Available _READY Family Name: U...

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PERSONAL DATA / APPLICATION FORM Position applied for __ CH. MATE / MASTER__ License hold ___DEEP SEA CAPTAIN____ Date Available _READY Family Name: Ustinov Name: Roman Father's name: Georgiy Date of birth: 14.01.1974

Place of birth: Feodosiy

Nationality: Ukraine

Address:…97, 41, Latisheva av., Mariupol, Ukraine…87553…………………………………………………………… E-mail: [email protected]

Nearest Airport…Zaporogie ……………………….. ..…………………………………………..

Marital status: married Home phone:…38-0629-515000 Mobile phone: 38-097-4535657(Ukraine)

Children (name & DOB): Ustinova Anastasiy 21.04.2005, …………………………………………… Ustinova Dariy 28.11.2008 ……………… Next of kin’s address:91, 41, Latisheva str., Mariupol, Ukraine Next of kin tel: 38-067-7367359 Inter. P’port No: EA 472657 Issued: 04.12.2007 Valid: 04.12.2017 Place of issue: Mariupol Seaman's book No: AB 456922 Issued: 04.05.2012 Valid: 04.05.2017 Place of issue: Port of Mariupol Place of issue: Mariupol Date of issue: 18.03.1997 Civil P’port No: BA 635486 Issued:Oct 2010 Valid:Oct 2015 Place of issue:Kiev,Ukraine USA visa No: С8250581 SEA GOING EXPERIENCE FOR THE LAST 5 YEARS Next of kin and relationship: spouse Ustinova Irina

( MOST RECENT VESSEL LAST )

Name of vessel

Company Owner/ Ship Manager

Flag

SMIT LUMUT

Year of built 2008

SMIT

SINGAPORE

AHTS

DWT/ TEU 1828

RAWABI 2

2011

RAWABI

FUNAFUTI

AHTS/DP-1

RAWABI 2

2011

RAWABI

FUNAFUTI

ZAMIL-3

1996

ZAMIL

ROBALO I

1976

ROBALO I

1976

CD-P03 Application Form

Type of vessel

ME type / Model

BHP

Rank

From Day,mont,year

To Day,month,year

6000

CH.OFF

25.03.14

12.06.14

1575

5125

CH.OFF

24.08.13

14.12.13

AHTS/DP-1

1575

5125

CH.OFF

02.02.13

22.05.13

BAHRAIN

AHTS

1331

4800

CH.OFF

05.07.12

24.10.12

ASTROMARITIMA

PANAMA

AHTS

1031

4200

MASTER

10.12.11

11.04.12

ASTROMARITIMA

PANAMA

AHTS

1031

4200

MASTER

03.04.11

10.09.11

Appendix 1

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ROBALO I

1976

ASTROMARITIMA

PANAMA

AHTS

1031

4200

CH.OFF

30.10.10

28.02.11

BOULDER

1986

MARINE CARRIER

HOLLAND

AHTS

2600

12000

CH.OFF

31.01.10

31.08.10

BOULDER

1986

MARINE CARRIER

HOLLAND

AHTS

2600

12000

CH.OFF

05.08.09

25.11.09

BOULDER

1986

MARINE CARRIER

HOLLAND

AHTS

2600

12000

CH.OFF

19.02.09

12.04.09

SARTOR

1976

NORWAY

PSV/PIPE CARRIER

2500

5000

CH.OFF

09.12.08

17.02.09

LIBERTY

1984

SARTOR OFFSHORE PLANTGERIA

NIGERIA

AHTS

1252

6000

CH.OFF

22.10.05

02.01.08

VIKING LADY

1980

PETROGAS

BAHANAS

PSV

550

900

CH.OFF

02.03.05

03.05.05

DELMAS MARULA

1982

DELMAS

BAHAMAS

CONTAIN

22000

17000

CH.OFF

02.09. 02

04.11. 03

ERIKOUSA WAVE

1980

TEO SHIPPING

CYPRUS

BC

21500

9000

CH.OFF

05.10.01

14.05.02

NAME OF SCHOOL ATTENDED Novorossiysk state marine academy

ADDRESS OF SCHOOL Novorossiysk, Russia

FROM 08.08.1991

TO 03.03.1997

STCW Certificates Certificate of competency Endorsement Personal safety Advanced fire fighting Prof. in survival craft

Number 00039/2004/06 00039/2004/06 8123 3950 6797

Issued 13.01.04 19.08.13 27.06.13 03.07.13 05.07.13

Valid Perman. 31.12.16 27.06.18 03.07.18 07.07.18

Place of issue Mariupol Mariupol Мariupol Mariupol Mariupol

STCW Certificates GMDSS Endorsement Radar observer ARPA FRC HUET

Bridge team & resources management Medical care Hazardous cargoes DP basic DP advanced

168HC

21.06.13

21.06.18

Mariupol

Security officer (ISPS)

567 5102

12.07.13 09.07.13 23.11.12 07.06.13

12.07.18 09.07.18

Mariupol Mariupol Odessa Odessa

ECDIS

Medical examination Drug & alcohol test Yellow fever MARLIN test CD-P03 Application Form

Issued:Jan 2014 Issued:Jan 2014 Issued:04.05.2012

Valid:Jan 2015 Valid: Valid:04.05.2022

Number 00423/2003/06 977 KC 977 KC 1118 3/AH/0023/0/ 13 000096/2014/0 3 813KC

Weight, kg:92 Eyes:blue Overall size:XXL

DEGREE OF DIPLOMA Engineer - navigator

Issued 23.07.13 14.06.13 14.06.13 25.04.12 30.01.13

Valid 14.06.18 14.06.18 14.06.18 25.04.17 30.01.18

Place of issue Mariupol Mariupol Mariupol Mariupol Illichivsk

05.02.2014

05.02.2019

Mariupol

05.08.2013

05.08.2018

Mariupol

Height, cm:176 Hair:braun Safety shoes:43

93% Appendix 1

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Nationalities of crew sailed with:

CD-P03 Application Form

German, Poland, Greek, Philipinos, Peruvian, Turkish, Bulgarian, Romanian, Kiribati, Ganian, Jamaican….

Appendix 1

Second Issue

Revision 0

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