CREW 27 – APPLICATION FOR EMPLOYMENT

CREW 27 – APPLICATION FOR EMPLOYMENT

Applied Company:
Personal Data
First Name: Artem Middle Name: Ruslanovich Last Name / Surname: Ruslanovych

Nationality: Ukranian Date Of Birth (dd/mm/yy) Place of Birth: Ukraine

30.04.2006
Position Applied For: engine Female ✓Male Available date:03.05.2024
cadet

Home Address:Ukraine,Kherson Personal Documents Issued on Valid until

Passport (Country / Number) 23.07.2020 23.07.2024

Seaman’s book 22.06.2023 22.06.2028

USA C1/D visa

Telephone:+380507019609 Schengen Visa

E-Mail:[email protected] Medical Fitness Certificate

Tanker Endorsements
National Certificates of Competence country:Ukraine
Management level Operation level
Grade Issued Expires Oil Chemical Gas

Valid Flag State Liberia , Panama , Malta , Marshall Islands , UK , Singapore Norway (NIS) ,
Endorsements Italy Other (list flags)
GMDSS Flag State GMDSS Endorsements (list)
General /Restricted

Other valid certificates and training attended

✓Basic Safety Training ✓Advanced Fighting ✓Medical First Aid Medical Care ECDIS (Generic)
Ship Security Officer Bridge Team Management Ship Handling Liquid Cargo Handling
ER Management ECDIS (Type Specific) Other (specify)

Education History: Name of Institution / Level / Graduate Date: Maritime applied college of KSMA / Junior professional bachelor / 2025

Please answer the following questions:

 Did you suffer, or presently suffer from, any disease likely to render you unfit for services at sea or
likely to endanger the health of other persons on board?
If yes, please provide details _______________________________________________ YES ✓NO
______________________________________________________________________

 Did you suffer any accident, which rendered you temporary and/or partially disabled? YES ✓NO
 Did you ever undergo psychiatric treatment YES ✓NO
 Are you addicted to alcohol or drugs of any kind? YES ✓NO
I hereby declare that the above facts and information are true and accurate. I further consent to the holding and processing by (i) the owners of any vessel on which I may be assigned from
time to time and (ii) the Managers and any direct or indirect parent or subsidiary or associated or affiliated company of the Managers (together referred to as "the Companies") for the
purposes of my employment, of personal data about me contained herein, or provided to any of the Companies at a later date, including with respect to personal and pensions
administration, employee management and as required to comply with any laws, regulations or contracts applicable to any of the Companies or their businesses. I understand that this data
will be stored in the Managers’ database for the purposes of my current or future employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my
personal data within the Managers’ organization.
Place___________________________ Date ___________________________ Signature ______________________________
For Office Use Only
Initial assessment of applicant for further recruitment
Comments

Document Number Version Number Date Approved By

CREW 27 01 Dec-2023 Group HSSEQ

1
 CREW 27 – APPLICATION FOR EMPLOYMENT

Responsible person

Name / Signature _______________________________________________ Date ________________________________

Document Number Version Number Date Approved By

CREW 27 01 Dec-2023 Group HSSEQ

2
 CREW 27 – APPLICATION FOR EMPLOYMENT
Sea Experience : (List the most recent experience first; use additional sheets as required)
Date From Date To Reason for S/off
Company Flag Vessel Name Type (1) GRT DWT Main Engine (2) BHP Rank (3)
(dd/mm/yy) (dd/mm/yy)

(1)
Use only the following abbreviations for vsl types:
*Please use only following abbreviations for the vessel type: (2)
Engineers to give make/model of engines, e.g. “MAN
GCD General Cargo MLP Multi-Purpose B/C Bulk Carrier CON Container O/O Ore Oil OBO Ore/Bulk/Oil 14V52/55A” or “SULZER 5RTA58”
(3)
TNC Tanker Crude TNP Tanker Product TNV VLCC/ULCC CHM Chemical Tanker LPG/LNG Gas Tanker FSO / FPSO Reason of Sing Off, e.g. “EOC – End of Contract”,
PAS Passenger Ship R/O Ro/Ro DRG Dredger NVL Naval Ship H/L Heavy Lift “MED – Medical Ground”, “OWN – Own request”
OSV Offshore Supply SRV Survey vessel LOG Log/Timber SSHL Semi-Submergible MOB Mobile Offshore Unit
Please provide details of two recent employers who we may contact for references
Name of Company
Name of person to contact
Address

Telephone/E-Mail

Document Number Version Number Date Approved By

CREW 27 01 Dec-2023 Group HSSEQ