APPLICATION FORM

1. Position Second class motorman 2. Filled 100% 3. Ready At any time

In accordance with seaman’s book in English language
4. Surname Dobriian 5. First name Serhii
6. Father name Andriyovych 7. Citizenship Ukrainian
8. Date of birth 31.01.1997 9. Place of birth Zaporizhia region, Ukraine
10. Nationality Ukraine 11. Religion Orthodox
12.Home address №135, Gagarina Str., village of Kyibushevo, Zaporizhia region, 71000/71001, Ukraine 13.Personal details (in Ukrainian units of measurements)
(apartment, building, street, city, region, postal zone, country) Hair Blonde
14.Phone/Mobile /E-mail +380666122735(main number); +380636944213; +380989271391 Eyes Green
s.d.serega@mail.ru Height
15.Marital status Married Divorced Single (Never married) Separated Widowed Weight
16.Children’s Under 18 Yrs: Dates of birth APPLICATION FORM: Headdress
17.Next of kin /Relation Relation: Dobriian Andrii Dmytrovych(father) - 0994631288, Dobriian Natalya Vladimirovna(mother). Shoes size 42-43
(relation, surname, name, father name) Overall size S
18.Next of kin address №135, Gagarina Str., village of Kuibyshevo, Zaporizhia region 19.Distinguish marks
(apartment, building, street, city, region, postal zone, country)
20.Agency remarks
Expected Wage: about 500 dollars for month

Ukrainian Educational diploma
Speciality Educational Institute name (22.) and address (23.) Diploma Issued Higher
21. Motorman 22. Nikolaev centre of training of seafarers 23.№2, Morekhidna Str., Nikolaev, Ukraine, 54021 24. Certificate of awarding (improving) of trade qualification Motorman № 059657 25. 11.03.2015

Ukrainian Certificate of Competency and Endorsement
Speciality Given by Number Issued Valid
26. Motorman 27. Certificate of awarding (improving) of APPLICATION FORM trade qualification Motorman № 059657 28. 059657 29. 11.03.2015 30.
31.Second class motorman 32. CERTIFICATE OF PROFICIENCY 33. 11686/2015/07 34. 06.07.2015 35.

English(degree/mark) FLUENT GOOD FAIR BASIC
Other languages 36.A little French, Russian and Ukrainian - fluent

Ukrainian Passports and Medical documents
Document 37.Number 38.Issued 39.Valid 40.Issued Place
Ukrainian passport СЮ297822 27.03.2013 Kuibyshevo RS UGMS Ukraine in Zaporizhia region
Travel passport FA324538 08.05.2015 08.05.2025 Authority - 4801
Seaman’s Record Book № 00158/2015/26 09.02.2015 Nikolaev
Medical Certificate of Seaman № СА 181-15 13.05.2015 13.05.2016 Nikolaev Medical Center
Seaman’s book АВ541509 02.03.2015 02.03.2020 Port Nikolaev
Drug and alcohol
Yellow fever

Previous sea service 41.Sea service since
42.Name of vessel 43.Flag 44.Type 45.Dwt 46.Engine 47.HP 48.Owner 49.Rank 50.From 51.Till
GS-82 UKR Hydrographic 2x820 Ukraine, Nikolaev APPLICATION FORM region Goshydrographic Trainee-motorman 23.12.14 28.02.15
52.Remarks: Produced being on a working watch under the direction of Chief engineer

Ukrainian STCW – 78/95 and other certificates.
Document 53.Number 54.Issued 55.Valid 56.Issued Place
Basic Safety Training 17.12.2014 17.12.2019 Ukraine, Nikolaev Centre of Training of Seafarers
Proficiency in Survival Craft
Proficiency in Fast Rescue Boats
Security duties of shipboard
Security related training
Advanced Fire Fighting
Medical First Aid
Medical Care
GMDSS Certificate
GMDSS Endorsement
Radar Observation & Plotting
Automatic Radar Plotting Aids
Dangerous & Hazardous Cargoes
Hazardous materials
Ships Safety Officer
Ships Security Officer
Isolating Breathing Apparatus
RO-RO Passenger Ship
RO-RO Ship
Oil Tanker Familiarization APPLICATION FORM
Oil Tanker Specialized Training
Gas Tanker Familiarization
Gas Tanker Specialized Training
Chem. Tanker Familiarization
Chem. Tanker Specialized Training
Crude oil washing
Inert Gas Systems
Bridge Resource Management
Vapor Recovery Systems
Refresher & Updating
Maintenance of electrical and electronic engineering
ISM code



Flag state passports, licenses, visas and other documents
Document name/Details Number/Comment Issued Valid Issued Place
57. 59. 61. 62. 63.
58. 60.

Reference
Extra Master
Extra Chief Engineer

Signature of Seaman ____________________ Operations manager ____________________


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