BSM APPLICANT’S PERSONAL DATA

POSITION APPLIED FOR: THIRD MATE / READY TO WORK (DATE): 01.11.2017
FIRST / LAST NAME: KOLESNICHENKO ALEXANDER / CITIZENSHIP: RUSSIAN FEDERATION /
FATHER’S NAME: ALEXANDROVICH / ADDRESS (incl. post code): 344058 RUSSIA, ROSTOV-ON-DON, STABILNAYA STR.7,FLT.415
DATE OF BIRTH: 02.10.1984
RELIGION: ORTHODOXAL
PLACE OF BIRTH: USSR
PHONE:
MOBILE:+7-951-500-91-87 / E-MAIL:
SKYPE: alexander-kolesnichenko1
MARITAL STATUS: SINGLE / MARRIED / DEVORSED / NEXT OF KIN: (if not married)
DATE OF MARRIAGE: 16.12.2016
WIFE’S FIRST / LAST NAME: KOLESNICHENKO SVETLANA / RELATION: WIFE
FATHER’S NAME: VLADIMIROVNA / FIRST / LAST NAME :
WIFE’S DATE& PLACE OF BIRTH: 14.09.1983, USSR / FATHER’S NAME:
ADDRESS: RUSSIA,STABILNAYA STR.7,FLT.415 / ADDRESS:
PHONE:
MOBILE:+7-904-445-50-32 / PHONE:
MOBILE: :
CHILDREN (IF APPLICABLE):
FIRST/ LAST NAME : / DATE OF BIRTH :
KOLESNICHENKO EUGENIA / 25.08.2005
KOLESNICHENKO KONSTANTIN / 10.08.2017
FIRST/LAST /MIDDLE NAME of MOTHER / FIRST/LAST /MIDDLE NAME of FATHER
KOLESNICHENKO EUGENIA VIKTOROVNA / KOLESNICHENKO ALEXANDER GRIGORIEVICH
CLOTHES:
/ SIZES: / HEIGHT / 177 / VISA / PLACE OF ISSUE (CITY) / TYPE OF VISA / FROM / VALID TILL
OVERALL
/ 52 / WEIGHT / 86 / USA / ST.PETERSBURG / C1/D / 26.06.2017 / 21.06.2019
SAFETY SHOES / 44 / COLOR OF EYES / BROWN / SCHENGEN
TROUSERS / 36 / COLOR OF HAIR / BLOND / / / / /
SWEATER / 50-52 / CHEST (Cms) / 118
SHIRT / 50-52 / WAIST (Cms) / 100
MARINE EDUCATION RECEIVED

NAME OF SCHOOL

/ FROM / TILL / TYPE OF DEGREE RECEIVED
STATE MARITIME UNIVERSITY OF ADMIRAL F.F.USHAKOV / 2009 / 2012 / NAVIGATOR
NATIONAL DOCUMENTS (RUSSIAN): / NO. / ISSUED / VALID
SEAFARER’S IDENTITY DOCUMENT / RUS 0301552 / 08.10.2015 / 07.10.2020

SEAMAN’S BOOK

/ MK 0057301 / 10.12.2010 / UNLIMITED
TRAVELLING PASSPORT / 712370051 / 02.11.2010 / 02.11.2020
CIVIL PASSPORT / 6008 123299 / 25.12.2007 / 25.12.2029
GRADE / NO. / ISSUED / VALID
NAT.LICENCE: / OOW / TAG201642039 / 31.08.2017 / 11.07.2022
ENDORSEMENT : Oil Chem LPG
/ OPERATIONAL / TAG201818903 / 11.10.2017 / 10.10.2022
GMDSS: / OPERATIONAL / TAG201641992 / 31.08.2017 / 30.08.2022
ENDORSEMENT:
RADAR OBSERVER: / IMO RES. A483 (XII) / 0072939 / 13.07.2017 / 13.07.2022
ARPA : / IMO RES. A482 (XII) / 0834164 / 17.07.2017 / 17.07.2022
CERTIFICATES: / STCW CODE / NO / ISSUED / VAILD TILL

BASIC SAFETY STCW ‘95

/ A-VI/1 / 0895367 / 11.07.2017 / 11.07.2022
SURVIVAL CRAFT, RESCUE BOATS: / A-V1/2-1 / 0895811 / 28.07.2017 / 28.07.2022
ADVANCED FIRE FIGHTING : /

A-V1/3

/ 0833741 / 04.08.2017 / 04.08.2022
MEDICAL EMERGENCY FIRST AID / A-V1/4-1 / 0803406 / 08.08.2017 / 08.08.2022
MEDICAL CARE CERTIF. / A-V1/4-2 / 0000819 / 10.08.2017 / 10.08.2022
DESIGNATED SECURITY DUTIES (SSD) / A-VI/6, A-VI/6-2 / 0834098 / 02.08.2017 / 02.10.2022
SHIP SECURITY OFFICER (SSO) / A-VI/5, A-VI/5 / 0087028 / 31.01.2014 / 31.01.2019
BRIDGE TEAM MANAGEMENT / ERM
BRIDGE TEAM MANAGEMENT IMO 1.22
ECDIS / 0834195 / 25.07.2017 / 25.07.2022
ECDIS SPECIFIC
OIL TANKER / FAMILIARIZATION /PROG. / A-V/1, P.2-7 / 0913583 / 10.10.2017 / 10.10.2022
OIL TANKER / SPECIALIZED / PROG. / A-V/1, P.9-14
CHEM TANKER / FAMILIARIZATION/ PROGR. / A-V/1, P.2-7 / 0913583 / 10.10.2017 / 10.10.2022
CHEM TANKER /SPECIALIZED/ PROGR. / A-V/1, P.16-21
LIQUID GAS TANK/FAMILIARIZATION/ PROGR. / A-V/1, P.2-7
LIQUID GAS TANK/SPECIALIZED / PROGR. / A-V/1, P.23-34
HAZMAT / B-V/4, B-V/5 / 0334954 / 16.08.2017 / 16.08.2022
HAZMAT (USA-TITLE 49) / 0011970 / 26.05.2017 / 26.05.2020
CRUDE OIL WASHING OPERATIONS/ INERT GAS SYSTEM
YELLOW FEVER / 04.03.2015 / 04.03.2025
FLAGS DOCUMENTS:

LIBERIAN

/

GRADE

/ NBR / ISSUED / TILL /

PANAMANIAN

/ GRADE / NBR / ISSUED / TILL

SBK

/

SBK

END. TO LIC / END. TO LIC
END. TO GMDSS / END. TO GMDSS
GMDSS / GMDSS
SPECIAL QUALIFICATION
CERTIFICATES / SPECIAL QUALIFICATION
CERTIFICATES
GERMAN / ANT&BARBUDA / /

SBK

/

SBK

/ OOW /

135183

/ 04.03.2014 / 03.03.2019
END. TO LIC / END. TO LIC / OOW / 2020308601 / 04.03.2014 / 02.11.2017
END. TO GMDSS / END. TO GMDSS / GOC / 1002507*2022302364 / 04.03.2014 / 10.12.2018
DUTCH

SBK

/ MARSH. ISLAND
END. TO LIC / SBK
END. TO GMDSS / END. TO LIC
GMDSS / END. TO GMDSS
SPECIAL QUALIFICATION
CERTIFICATES / SPECIAL QUALIFICATION
CERTIFICATES
CYPRUS / MALTA
SBK / END. TO LIC
END. TO LIC / / END. TO GMDSS /
END. TO GMDSS / / BAHAMAS /

NIS

/ END. TO LIC

SBK

/ END. TO GMDSS
END. TO GMDSS / SINGAPORE/ HONG KONG
END. TO LIC / END. TO LIC
GMDSS / END. TO GMDSS
SPECIAL QUALIFICATION
CERTIFICATES
OTHER DOCUMENTS (NOT MENTIONED BEFORE)
DOCUMENT / GRADE / NO. / ISSUED / VALID
SEA SERVICE LAST 5 YEARS (10 FOR MASTERS AND CHIEF ENGINEERS)
VESSEL’S NAME / COMPANY (SHIP’S OWNER/ CREWING) / FLAG / VSL’S
TYPE / TEU/
CARGO / GRT/
DWT / ENG.TYPE / HP/
KW / RANK / EMPLOYMENT
(M/Y) / TOTAL
FROM / TO
“SAILCOUNTESS” / SAILTRADE / RUSSIAN / D.CARGO / 2454mts / 3201 / SKL / 1030 / 3/O / 22/04/2013 / 05/11/2013 / 6m14d
“POLLUX” / MARLOW NAV. / A&B / G.CARGO / 2452mts / 3689 / MAK / 1500 / 3/O / 21/04/2014 / 23/10/2014 / 6m2d
“PRIWALL” / MARLOW NAV. / A&B / G.CARGO / 2446mts / 3735 / DEUTZ / 1500 / 3/O / 22/02/2015 / 07/09/2015 / 6m12d
“SEATON” / MARLOW NAV. / MARSHALL / BULKER / 5164mts / 7492 / DAIHATSU / 2500 / 3/O / 09/12/2015 / 09/04/2016 / 4m
“ARA AMSTERDAM” / MARLOW NAV. / GIBRALTAR / MULTI / 6154mts / 8100 / WARTSILA / 4350 / 3/O / 25/08/2016 / 04/11/2016 / 2m10d
“ZIM RIO GRANDE” / DANAOS / MALTA / CONTAINER / 4250TEU / 50842 / MAN / 36560 / 3/O / 10/05/2017 / 26/09/2017 / 4m16d
SHIP OWNER’S DATA
COMPANY / TEL / CONTACT PERSON
DANAOS Shipping Co. / +7(812)386-38-01 / Tatyana (Crew Department)
CREW AGENCIES DATA
VESSEL / CREW AGENCY / TEL / CONTACT PERSON

С автоматической обработкой моих персональных данных, указанных в анкете, их передачей третьим лицам (включая трансграничную) и хранением в целях трудоустройства в соответствии с Федеральным законом РФ №152-ФЗ согласен. Подтверждаю, что мои персональные данные, указанные в анкете, являются общедоступными.

SIGNATURE OF SEAMAN (подпись моряка): DATE: 30.10.2017