Synergy Maritime Recruitment Services Pvt. Ltd.
,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024
Present Rank : 2nd Officer Rank Applied for : 3rd Officer
Surname : Mazur Tel No. 79781843718
Name Sergei Alternate Tel 79066322873
live:mockvavmf
Email ID mockvavmf@gmail.com Skype ID White background. 80%
Date Of Birth (DD/MM/YYYY) 5/18/1996 Place of Birth : Ukraine Face
Nationality : Russian Marital Status : Married
Date of Availability : 2/10/2024 Boiler Suit Size : L
Height(cms) 177 Weight(kgs) 78 Blood Group A2+ Shoe Size : 10
62 Antique str. Appt 21 Sevastopol Russia
Address :
Nearest Airport
PAN No for
AADHAR for Indian Indian MUI/NUSI or any other
Nationality Nationality Union Membership No
English Language Proficiency : Speak Average Read Good Write Good
Documents Number Place of Issue Date of Issue Date of Expiry
Passport 0319182026 Russia 12/25/2018 12/21/2035
National CDC 308700 Russia 10/10/2018 Nil
Biometric SID 759925527 Russia 1/29/2018 1/29/2028
U.S. Visa C1/D
Schengen Visa
Grade/
Documents Level Number Issuing Authority Date of Issue Date of Expiry
National Certificate of
Competency (COC) 207248151 Russia 10/3/2022 6/25/2026
CoE - Panama 203788731 Panama 11/10/2022 6/25/2026
CoE - Marshall
CoE - Singapore
CDC - Marshall Islands
CDC - Panama 005402 Panama 11/10/2022 6/25/2026
CDC - Liberia
INDoS No
STCW Certificates Number Name of MTI Date of Issue Date of Expiry
PSSR 1022050590 Russia 1/18/2022 1/18/2027
PSCRB 8012065655 Russia 8/5/2021 8/5/2026
PST
AFF 6012060396 Russia 6/25/2021 6/25/2026
MFA 1022051522 Russia 1/27/2022 1/27/2027
STSDSD 8012065806 Russia 8/7/2021 8/7/2026
High Voltage Training
National Endorsements Number Issuing Authority Date of Issue Date of Expiry
(Where applicable)
GMDSS 207248034 Russia 10/7/2022 10/28/2026
Adv Oil Endorsement 207732077 Russia 7/14/2023 10/12/2027
Basic/Adv Chemical
Endorsement
Basic/Adv Gas
Endorsement
Navigation & Main Date of Expiry
Engine Training Number Name of MTI Date of Issue (Where applicable)
BTM
ECDIS - Generic 7012061750 Russia 7/3/2021 7/3/2026
ECDIS - Type Specific I SID248420K/141460 Panama 10/27/2022 10/27/2023
ECDIS - Type Specific II
ME Engine
RT Flex
Ed 01 Rev No 0
FORM : M 01 Page 1 Of 2
Date:10-Jan-2020
Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024
LICOS 03712 Russia 10/6/2022 10/6/2027
Academic Background
Qualification Name of Institution Board / University Date of Passing Grade /
Percentage
10th Std (SSLC) /Equivalent
12th Std (Hr. Sec) / Equivalent
Pre Sea Training Nakhimov Naval School University 9/1/2017 6/10/2021
Any other Qualification
Family Details - all dependant
No. Name Relation D.O.B Sex Passport No Place of Issue Date of Issue Date of Expiry
1 Kotovskaya Olga Mother
2 Mazur Darina Wife
3
Previous Sea Experience (All Sea Service details from Cadets/Jr level. List recent vessel first)
Deck (Trade & DWT) Period Dates
Type of
Vessel's Name Engine (Type & BHP) Company's Name Rank
Vessel/Flag From To Months/Days
TEU (Containers)
ST.OLGA W/W 28202 Bulk Carrier /Pan Levant Shipping BIB INC 2/O 8/19/2023 12/21/2023 4/2
ST.OLGA W/W 28202 Bulk Carrier /Pan Levant Shipping BIB INC 3/O 10/26/2022 5/4/2023 6/8
Ivory Gull W/W 33000 Bulk Carrier /Liber Roswell navigation corporation OS 10/4/2021 2/28/2022 4/24
Ivory Gull W/W 33000 Bulk Carrier /Liber Roswell navigation corporation OS 7/28/2020 1/28/2021 6/0
Ice Eagle W/W 19740 Crude Oil Tanker/R Roswell Arctic OS 8/16/2019 11/20/2019 3/4
Ice Eagle W/W 19740 Crude Oil Tanker/R Roswell Arctic Deck Cadet 4/19/2019 8/15/2019 3/27
Last Employer name AV Marine PIC & Contact No / Email ID: avmarine@list.ru / +7 978 847 53 64
Break in sea service of more than 12 months from last sign off If yes, Candidate to submit self-declaration background security check Form M02 at the
Yes / No
time of Evaluation
Summary of Sea going Experience
For all Officers: Period served on (yy/mm)
BULK CNTR OIL TNKR CHEMICAL
Handymax Panamax Capsize Centre- Feeder Ctnr >8000 Ctnr >14000 Prod. Tanker Aframax VLCC OIL& Chem Parcel
1/9 0/7
For Engineer Officers only : Period served on (yy / mm)
Sulzer B&W MAN Pielstick UEC Doxford Steam UMS CPP Cranes MAK / 4-Stroke
Pump Experience (in months) for All Tanker Seafarers
FRAMO 7 COP
If Yes, in which
Have you been on board vessels during: Drydocking Yes / No Rank No New
Construction Yes / No If Yes, in which
Rank
Have you been involved in any Incidents of Grounding / Fire / Explosion / Collision / Abandon Ship / Rescue / Major oil No
Pollution / Drug Smuggling / Towed or Towing another vessel. If yes, please specify
No
Have you been involved in a court of Enquiry for a Maritime accident ? If yes, please specify
No
Have you ever been involved in a criminal case : If yes on any of the above , give details:
No
Has your present or previous certificate ever been suspended / revoked ? If yes, give details:
No
Do you suffer or have suffered from : Diabetes / High Blood Pressure / Hepatitis / Epilepsy / Nervous Disorders/
Disturbed Vision Or Hearing / Vertigo If yes, give details :
Are you a habitual user of Drugs / Narcotics / Excessive Alcohol. If yes, give details: No
Have you previously worked with multinational workforce? If Yes, What nationalities: No
Declaration by the Applicant:
I understand that a strict medical examination including Drug and Alcohol test as per company requirements is a condition of my employment and I express my willingness to be examined.
I undertake to provide the company’s medical officer full details of my previous medical history. I agree that the decision of the company medical officer is final.
I declare that there are no criminal/ police investigations in progress against me.
I confirm that all my travel documents are valid and in order. I understand that if my travel Documents become invalid or restricted at any time during the course of my employment and cannot be
revalidated by me under normal process, the contract of employment will terminate and all costs of repatriation will be borne by me.
I am /am not presently employed elsewhere.
I am aware that Synergy Maritime Recruitment Services Pvt Ltd., does not have any agents in India for employing Seafarers.
If my application is successful, I will be available to report at your office on or after:_____YES____
If this application sent through candidate's email id, applicant's signature is not required. Candidate should submit the signed application form during the evaluation process/PJF
Name Of Applicant Mazur Sergei Date 1/24/2024 Signature of the Applicant
Ed 01 Rev No 0
FORM : M 01 Page 2 Of 2
Date:10-Jan-2020
Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024
White background. 80%
Face
Sochi
Ed 01 Rev No 0
FORM : M 01 Page 3 Of 2
Date:10-Jan-2020
Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024
Grade /
Percentage
6/10/2021
79780664095
79788408909
Reason for S/off
end of the contract
end of the contract
end of the contract
end of the contract
end of the contract
transfer to another position
ne@list.ru / +7 978 847 53 64
ion background security check Form M02 at the
GAS
Gas
ME B/C
No
No
No
No
No
No
No
No
press my willingness to be examined.
er is final.
the course of my employment and cannot be
ng the evaluation process/PJF
Ed 01 Rev No 0
FORM : M 01 Page 4 Of 2
Date:10-Jan-2020
