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KSS-TRANS
Marine Agency Company
Ukraine, Nikolaev,15 Bugskiy Bulvar
tel/fax (80512) 76-52-69
+38 093 134 15 00 +38 099 08 00 984 +38 067 515 36 42
E-mail [email protected] www.kss-trans.com.ua
(ISO 9001:2008 & MLC 2006 compliance)
Validity — 30/09/2017
Position applied for:
Minimum acceptable salary:
Remarks:
SURNAME
NAME
FATHER'S NAME
Date and place of birth:
Address:
Personal civil code:
Home 
Mob 
E-Mail :
SKYPE :
ICQ :
W eight
Height
Overall
Shoes
Eyes
Hair
USA visa valid:
Y
e
l
l
o
w
F
e
v
e
r
v
a
l
i
d
:
Medical card valid:
Marital status select from: ●Single ●Married ●Divorced ●Common Law Partner ●Widowed ●Separated
Title of the document
Seaman's book
National passport
Foreign passport
Cyprus passport
Panama passport
Other passport
Rank
Certificate of competency
Endorsement
Others Professional license - Rank
Certificate of competency
Endorsement
G.M.D.S.S. General Operator (A-IV/2) Certificate
G.M.D.S.S. General Operator (A-IV/2) Endorsement
Basic Safety Training and Instruction (НБЖС) (A-VI/1)
Proficiency in Survival Craft, Rescue Boats & Fast Rescue Boats (A-VI/2)
Advanced Fire Fighting (A-VI/3)
Carrying dangerous & hazardous cargo (B-V/4, B-V/5)
Radar Observation and Plotting (A-II/1,2)
Automatic Radar Plotting Aids (ARPA) (A-II/1,2)
Ship’s Medical Care (A-VI/4-2)
Medical First Aid (A-VI/4-1)
Ro-Ro passenger ships (A-V/2)
Refresher and updating courses (II/1)
Passenger ships other than Ro-Ro (A-V/3)
Certificate of ISM code (A-1/14)
SHIPS SAFETY OFFICER
SHIPS SECURITY OFFICER
Bridge team management
Familiarization course on ship and port facility security for crew
Security-Related Training and Instruction for all Seafarers (A-VI/6-1)
Designated Security Duties of Shipboard Personnel (A-VI/6-2)
№
Date of
issue
Expire
date
Place of
issue
№
Tanker Certificates:
Date of
issue
Expire
date
Place of
issue
Chemical Tanker (Advanced and Familiarization, A-V/1, p.2-7)
LPG carrier (Advanced and Familiarization, A-V/1, p.2-7)
Oil Tanker (Advanced and Familiarization, A-V/1, p.2-7)
Cargo equipment on Tankers (A-V/1, paragraph 1)
Crude oil washing
Inert gas system
Tanker Familiarization course
PREVIOUS SEA EXPERIENCE (FOR LAST 10 YEARS):
RANK
NAME OF THE
VESSEL
TYPE
VESSEL
FLAG
YEAR
OF
BUILD
DW T
HP
TYPE OF
THE MAIN
ENGINE
F RO M
TILL
COMPANY
(name, address, )
MARINE EDUCATION RECEIVED
NAME OF SCHOOL
FROM
TILL
TYPE OF DEGREE RECEIVED
ADDITIONAL INFORMATION
Child (Name and Date of Birth) :
Next of kin :
Name:
Address:
Date of birth:
Home :
Mob :
LEVEL ENGLISH TEST
English language knowledge
Excellent
Good
Satisfactory
P oor
Computer proficiency
Excellent
Good
Satisfactory
P oor
Откуда вы узнали о нашей компании
Знакомые
Газета
Телевидение
Интернет
I, undersigned, confirm all above information to be true and correct to my best knowledge:
Date
Signature of the Applicant _______________
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