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ДЛЯ ПОСТАНОВКИ НА УЧЕТ:

1. Заполнить анкету, подписать сам файл фамилией и должностью на английском языке


2. Там где «Photo» поставить свою фотографию
3. Отсканировать все свои морские и гражданские документы в формате Jpg с
разрешением не менее и не более 100-150 пикселей
4. Отправлять письмо с пометкой в строке «ТЕМА» - ЗАПОЛНИЛ АНКЕТУ ТАНмар
5. При отправке электронного письма все файлы прикреплять к письму, можно архивом,
ССЫЛКИ НЕ ПРИНИМАЕМ!
НЕВЫПОЛНЕНИЕ ЛЮБОГО ПУНКТА ВЕДЕТ К НЕ ПОСТАНОВКЕ НА
УЧЕТ!!!

M A R IN E S E R V IC E S
49, B. Morskaya str., Nikolaev, Ukraine, Photo
tel +38098 402 94 64, +3095 080 19 93
E-mail: tanmar@ukr.net
APPLICATION FORM
PERSONAL DESCRIPTION:
Rank : Welder Surname: Balan Name: Ivan Middle Name:

Date of Birth: 24 May Place of Birth: Odessa reg, Citizenship: Ukrainian Marital Status: Single
1994 Plotsk village

Address: Ukraine, Odessa region, Plotsk village, Lenin street 67 Phone: +380 96 565 01 45
Next of Kin: Balan Grigoriy - Address: Ukraine, Odessa region, Plotsk Phone:
father village, Lenin street 67
ENGLISH: lower than average Total Experience: 11 months e-mail:
balanivan20@gmail.com
GENERAL DETAILS:
Documents № Issued Valid Until Place
National Passport KM672396 08.10.2010 Artsiz
Traveling Passport BIO. FG996643 17.07.2017 17.07.2027 Kyiv Size:
Traveling Passport High: 177
Seaman’s Book AB595869 22.02.2017 22.02.2022 Izmail Shoes: 43
Medic. cert. Weight: 80
PRE-SEA EDUCATION:
Name of Marine School Department Graduated on
Odessa Professional Lyceum Welder & Ship Hull
2009-2012
of Maritime Transport Repairman

CERTIFICATES OF COMPETENCY:
№ Grade Place of issue Date of issue/validity
National 01095/2018/01 Welder Izmail 29.08.2018
Endorsement
National
Endorsement
GMDSS
Endorsement
FLAG STATE PASSPORTS, LICENSES, VISAS AND OTHER DOCUMENTS
Document name/Details Number Issued Valid

SEA SERVICE (DURING LAST FIVE YEARS)


Vessel’s ME type/ From To
№ Rank Vessel’s Name Company Flag
type/DWT HP month/year month/year
Erato
OS/ 15.03.201 13.08.201
1. m.v. Muse 3811 mt 1280 kWt Shipping Malakal
Welder 8 8
Limited
2. AB/ m.v. Alby 26250 mt 8561 kWt AL&BY Panama 15.11.201 16.12.201
Shipping
Welder Destiny 8 8
S.A.
AL&BY
AB/ 16.12.201 22.01.201
3. m.v. Alby Story 25968 mt 9750 kWt Shipping Panama
Welder 8 9
S.A.
Antur
RoRo Line 02.08.201 12.12.201
4. Welder m.v. Mechta S. 3041 mt 1280 kWt Moroni
LLS – 9 9
U.S.A.
5.
6.
7.
8.

STCW – 78/95 and other certificates.


Document Number Issued Valid Issued Place
Basic Safety Training 13929 01.02.2017 01.02.2022 Ilychevsk
Proficiency in Survival Craft 9660 31.01.2017 31.01.2022 Ilychevsk
Proficiency in Fast Rescue
Boats
Advanced Fire Fighting
Medical Care
GMDSS Certificate
GMDSS Endorsement
Radar Observation & Plotting
Automatic Radar Plotting
Aids
ECDIS
Dangerous & Hazardous
Cargoes
Hazardous materials
Ships Safety Officer
Ships Security Officer
Isolating Breathing Apparatus
RO-RO Passenger Ship
RO-RO Ship
Oil Tanker Familiarization
Oil Tanker Specialized
Training
Oil T. cargo & ballast
handling hhhahandling
Oil T. Op.&maint. of inert
gas
Liq. Gas Tankers Spec.
Training
Liq. Gas Op.&maint. of inert
gas syst. T.cargo & ballast
Liq.Gas
handling
Chem. Tankers Spec.
Training
Chem. T. Op.&maint. of inert
gas
Chem. T. cargo & ballast
handling
Crude oil washing
Bridge Team & Res-s
Management
Ship Handling Arrangement
(M.L.)
ISM code
Designated Security Duties 11352 04.10.2017 04.10.2022 Odessa
Security

I, undersigned, confirm that all details provided on the form are correct.

Date: