LASKARIDIS SHIPPING CO.

,LTD ISUED ON 1ST OCT 2011

SEAMAN’S PRE-EMPLOYMENT CHECK LIST
A. PERSONAL DETAILS

Name Tsapukevych Yulian Petrovych

Surname First name Father’s name
Date and place of birth 3.01.2001 Izmail , Odeka reg,

Nationality Ukrainian Family State Ukrainian

Home Address Suvorova av, 201

(Permanent residence)
E-mail, tel. /mob 380931238813 [email protected]

Trade Education Danube Institute of National «Odessa Maritime Academy» 30.05.2022

( College / university / academy, date of graduation )

Marital status (married/single/divorced) Single
Wife Full Name
Beneficiary Full Name
Beneficiary Full Name relation
Beneficiary Address and tel.
Children names/age

Position applied for

B. NATIONAL AND FLAG CERTIFICATES
Title of the seafarer’s National documents Number Date of issue Place of issue Valid till
Seaman’s book AB 670353 05.11.2020 Port Izmail 05.11.2025
Travel passport FX909010 22.11.2019 5119 22.11.2029
Ukrainian domestic passport 6067968 11.05.2021 5119 11.05.2031
Certificate of competency (Capacity - officer in charge of
an engineering watch in a manned engine-room of 03823/2022/08 Harbour Master
07.07.2022
designated duty engineers in a periodically unmanned of seaport Odessa
engine-room)
Endorsement of Certificate (Limitations ,if any only for 03823/2022/08 Harbour Master
07.07.2022
ships powered by internal combustion engines) of seaport Odessa
Flag Endorsement of Certificate (Flag _______________ )
_______________
GMDSS certificate (Capacity ______________________)
Endorsement of GMDSS (Limitation, if any___________)
Flag endorsement of GMDSS (Flag__________________)
185080 01.09.2020 «Training Centre» 22.07.2025
of PJSC
Basic safety training Certificate «Ukrainian
Danube Shipping
Company»
Proficiency in Survival craft
185079 01.09.2020 «Training Centre» 09.07.2025
of PJSC
Proficiency in Survival craft and rescue Boat Certificate «Ukrainian
Danube Shipping
Company»
Advanced fire fighting Certificate 1454554 30.05.2022 MTC Whale 30.05.2027
Documentation of 15.04.2021 Marlow Navifation
Special Ukraine
Carriage of dangerous cargo Certificate Competency for
Safe Transport of
Dangerous Goods

Medical first aid / Medical care Certificate 1454577 30.05.2022 MTC Whale 30.05.2027
Radar navigation Certificate
ARPA Certificate
ECDIS Certificate
Ships Safety Officer Certificate
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SEAMAN’S PREEMPLOYMENT CHECKLIST CR03 REVISION: 3
LASKARIDIS SHIPPING CO.,LTD ISUED ON 1ST OCT 2011
Ship Security Officer Certificate(A –VI/6-2 STCW)
177863 31.07.2020 «Training Centre» 07.07.2025
of PJSC
Designated Security Duties «Ukrainian
Danube Shipping
Company»

188803 01.09.2020 «Training Centre» 22.07.2025

of PJSC
Security Related Training «Ukrainian
Danube Shipping
Company»

SATRO-335/21 14.05.2021 Kherson

Maritime
Spacialised
Security Awareness Training
Training Centre

Engine Room
Bridge team management Certificate
Oil tanker Familiarization
Crude Oil Washing
Inert Gas System
Oil Tanker Special
Chem.tanker Special
Liquified gas tanker
Medical certificate
Medical
Centre
Yellow fever vaccination Certificate 20.05.2021
UKRMED
TRANS
Drug and alcohol test Certificate

English language knowledge: Marlin’s test (%)

(very good/good/poor)
Working clothes size ______ Shoes size 43 Height 172 Weight 80_ Eyes color Hair Color brown
brown

C. SEA SERVICE ( last ten contracts)

Vessel’s name Type Flag DWT M/E Rank Signed Company
maker power on off
Calypso Heavy lift ANTI 11473 MAN 7200kW Engine 12.05.20 22.02.202 HPS Shipping and
GUA t Cadet 21 2 Management GmGh
and Co KG
Denev-1 Tug Liberia 230 1600kW Engine 01.03.20 31.03.202 River trans Service
t Cadet 22 2

D. OTHER INFORMATION
Previous Employment (please indicate the companies that he worked the two last contracts)

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SEAMAN’S PREEMPLOYMENT CHECKLIST CR03 REVISION: 3
LASKARIDIS SHIPPING CO.,LTD ISUED ON 1ST OCT 2011
Company name Address Phone Rank From To
Marlow Navifatio 45 Troitskaya Street Odessa 380687340800 Eng Cad 2021 2022
Ukrai ne

Other countries visits (USA, SHENGEN)

USA - 2021
(Specify the country and year of each visit for last 5 tears)

USA, Australia, Schengen VISA (Specify Country and validity date )

USA -31.03.2031 Australia - 04.05.2024

Are any Liabilities in progress? (Alimony, judicial claims and etc.)

All above-stated is true. The present I allow to store and use the information received from me with a view of my employment.

Date and applicant signature_______________

E. INTERVIEWER CONCLUSION

When available for Employment

Reference (from Whom, details)

Ability
Character
Qualification
Motivation
Remarks

Found Suitable____________ Hold for possible reconsideration __________ Not suitable _____________

Interviewer’s Name and signature

Date and place of Interview

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SEAMAN’S PREEMPLOYMENT CHECKLIST CR03 REVISION: 3