COMPANY WORK FORM Form No. F.6.
2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD
DATE AVAILABLE: 24.11.2019
POSITION APPLIED FOR: 2/O DPO
FULL NAME: ATTACH
SURNAME:Lukashenko PHOTO
FIRST NAME: Andrii HERE
MIDDLE NAME(S) Vladislavovych
PERSONAL DETAILS
DATE OF BIRTH 18.02.1986 PLACE OF BIRTH NATIONALITY HEIGHT 182
WEIGHT 75 kg HAIR COLOUR Brown EYE green
COLOUR
MARITAL STATUS single SPOUSE’S NAME No. of Nil
Children
FATHER’S NAME MOTHER’S NAME NEXT OF Mother
KIN
HOME ADDRESS TEL. No.
(PERMANENT)
OTHER ADDRESS TEL. No.
E-MAIL: SKYPE: HOMEPORT: Odessa Mob No. +380632670316
antario86@gmail.com
LICENCES / DOCUMENTS HELD
ITEM No. I S S U E D EXPIRING GRADE
DATE PLACE BY DATE
NATIONAL LICENCE 02505/20 26.10.2018 Ukraine Ch/Off
18/08
STCW ENDORSEMENT 02505/20 26.10.2018 Ukraine 25.10.2023 Ch/Off
18/08
MARSHALLS ISL. ENDORSEMENT
LIBERIAN ENDORSEMENT
OTHER LICENCE Offshore 10.04.2017 UK Nautical Inst 10.04.2022
Unlimite
d
PASSPORT ES67440 19.12.2014 Ukraine 5102 19.12.2024
8
NATIONAL SEAMAN’S BOOK/CDC AB53726 25.12.2014 Ukraine Port Ilyichevsk 25.03.2024
3
OTHER SEAMAN’S BOOK / CDC
U.S.VISA
YELLOW FEVER VACCINATION 19.06.2016 Ukraine 19.08.2026
P.R.C. No. (Filipino Crew only)
National data base of seafarers INDOS
Certificate No. (Indian personnel only)
CERTIFICATES HELD
ITEM No. ISSUED EXPIRING ISSUED BY
BASIC SAFETY TRAINING (*IF ONE CERTIFICATE) 12117 09.10.2018 09.10.2023 Ukr Seaferars Tr
Centre
PERSONAL SAFETY & SOCIAL RESPONSIBILITIES*
PERSONAL SURVIVAL*
SURVIVAL CRAFT HANDLING*
FIRST AID AT SEA (ELEMENTARY LEVEL)*
PROFICIENCY IN SURV.CRAFT/ RESCUE BOAT (PSCRB) 11065 09.10.2018 09.10.2023 Ukr Seaferars Tr
Centre
ADVANCED / SHORE-BASED FIREFIGHTING 07933 09.10.2018 09.10.2023 Ukr Seaferars Tr
Centre
PETROLEUM TKR SAFETY – BASIC/ GEN OIL TKR FAM.
MEDICAL FIRST AID 06756 09.10.2018 09.10.2023 Ukr Seaferars Tr
Centre
SHIP MASTERS MEDICARE/ADVANCED MEFA 01897 09.10.2018 09.10.2023 Ukr Seaferars Tr
Centre
PETROLEUM TKR SAFETY – ADVANCED/SPECIALISED
COW / IGS
DANGEROUS CARGO ENDORSEMENT - OIL
CHEMICAL TANKER SAFETY
Rev. 3 dated 30/09/15
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COMPANY WORK FORM Form No. F.6.2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD
LIQUIFIED GAS FAMILIARISATION
LIQUIFIED GAS SPECIALISED/ADVANCED COURSE
DANGEROUS CARGO ENDORSEMENT - LIQUIFIED GAS
LICOS (FOR LIQUIFIED GAS – PLS SPECIFY)
LIQUIFIED GAS-SPECIFIC FIRE FIGHTING – PLS SPECIFY
SIGTTO
STCW ENDORSEMENT
ARPA 01772 09.10.2018 Ukr Seaferars Tr
Centre
R.O.C. / RANSCO / RADAR SIMULATOR
SATCOM
\\\
APPLICANTS NAME:
_________________________________________________________
CERTIFICATES HELD (CONTINUED)
ITEM No. ISSUED EXPIRING ISSUED BY
GOC / GMDSS 02506/201 26.10.2018 25.10.2023
8/08
ECDIS 02052 09.10.2018 Ukr Seaferars Tr
Centre
SHIP MANOEUVERING/SHIP HANDLING SIMULATOR
SHIP SECURITY OFFICER 04140 09.10.2018 09.10.2023 Ukr Seaferars Tr
Centre
ISPS FAMILIARISATION
SHIPBOARD SAFETY OFFICER
ENGINE ROOM SIMULATOR
ENGINE ROOM RESOURCES MANAGEMENT
HUMAN RELATIONS
QUALITY AND SAFETY MANAGEMENT
RISK ASSESSMENT / RISK MANAGEMENT
MARINE ACCIDENT/INCIDENT INVESTIGATION
MANAGEMENT OF CHANGE
ENVIRONMENTAL COURSE / ISO 14001
MLC/LSC MARITIME LEADERSHIP COURSE
MARPOL I
MARPOL II
MARPOL VI
MARITIME ENGLISH
MLC 2006
BRIDGE TEAM MANAGEMENT 01548 09.10.2018 Ukr Seaferars Tr
Centre
BRIDGE RESOURCES MANAGEMENT 01548 09.10.2018 Ukr Seaferars Tr
Centre
RECORD OF PREVIOUS SERVICE (VERIFIED AGAINST SEAMAN’S BOOK ENTRIES)
COMPANY VESSEL’S TYPE/ DWT M/ENG’S BHP/ UMS RANK FROM TO MONTHS
NAME BUILT TYPE ( Y-
Bourbon Bourbon Liberty AHTS 1733 Cadet 07.08 11.09 Nigeri
232 DP 2 .2015 .2015 a
Bourbon Bourbon Liberty AHTS 1733 Cadet 11.09 13.10 Nigeri
237 DP 2 .2015 .2015 a
Bourbon Bourbon Liberty AHTS 1733 2/O 15.02 15.04 Nigeri
237 DP 2 .2016 .2016 a
Bourbon Bourbon Liberty AHTS 1733 2/O 16.09 08.12 Egypt
226 DP 2 .2016 .2016
Bourbon Bourbon Liberty AHTS 1733 2/O 17.07 17.08 Ivory
239 DP 2 .2017 .2017 Cost
Bourbon Bourbon Liberty AHTS 1733 2/O 01.11 26.01 Gabon
215 DP 2 .2018 .2019
Bourbon Bourbon Liberty AHTS 1733 2/O 02.05 23.07 Gabon
215 DP 2 .2019 .2019
Rev. 3 dated 30/09/15
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COMPANY WORK FORM Form No. F.6.2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD
Rev. 3 dated 30/09/15
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COMPANY WORK FORM Form No. F.6.2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD
APPLICANT’S NAME: ___________________________________________________________________
ACTUAL TIME SERVED IN MONTHS
OBO / CHEM. / BULK
RANK LNG LPG CRUDE OIL PRODUCT CARRIER/
TANKER TANKER OTHER
MASTER OR CH. ENG.
C/OFF OR 1A/E
2/OFF OR 2A/E
3/OFF OR 3A/E
GAS/CARGO ENGINEER
CADET/JR.ENG
ETO / ELEC (PLS STATE)
PMN / FITTER
OTHER RANK
ALLOTMENT DETAILS
SURNAME
NAME
MIDDLE NAME
DATE OF BIRTH
RELATIONSHIP
ADDRESS
NAME OF BANK
ACCOUNT No.
SSS No. (Filipino crew only)
TIN No. (Filipino crew only)
WIFE & CHILDREN’S NAME S DOB POB PASSPORT NO. DATE OF ISSUED AT
ISSUE EXPIRY
How long did you stay at your previous company?
Wages on last vessel?
Trade route of vessels?
Who referred you to the company?
Any relatives with the company?
If yes, who?
ANY OTHER INFORMATION ABOUT YOURSELF:
UNION MEMBERSHIP NO.: DATE :
DOE:
ALL APPLICANTS
DATE APPLICATION FILLED OUT
SIGNATURE OF APPLICANT
FULL NAME IN BLOCK CAPITALS
Rev. 3 dated 30/09/15
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