APPLICATION FORM
   
  1. PERSONAL DETAILS
Surname:   Ivanov	First name:  Petr	Patronymic:  Semenovich 	
Date of birth:  19.11.1956	Place of birth: Voronezh 	Nationality:   Russian	
Permanent Address: Ivanovskaya Str. 3-7; Kaliningrad, Russia              
	
Phone:  + 7 0112   111222	
  
  2. GENERAL DETAILS
Document	Number	 Date & place of issue	           Date of Expire	
Passport	43 N 9998888	12.03.1997; Kaliningrad	12.03.2002	
Seaman’s Passport	PФ 1122333	10.03.2000; Kaliningrad	10.03.2005	
Antigua & Barbuda SB				

  3. CERTIFICATES / QUALIFICATIONS
Type	Grade/Class	Number	Date of issue	Date of expire	Place of issue	
National licenses	Deep sea Captain 	8866/94	21.09.1994	21.09.1999	St.Petersburg 	
Endorsement	Master	5544/94	30.11.1999	30.11.2005	Kaliningrad	

						
  
  4. EDUCATIONS AND FURTHER SHORE EMPLOYMENT
Date from 	  Date to	Schools, Colleges	Exams Passed, Certificates Obtained	
1974	1978	Kaliningrad’s Secondary Marine School	1978; Short sea Navigator	

				

  5. ATTENDED DETAILS OF COURSES
Course	Date of issue	Date of expire	No of Certificate, Qualification, 
Educational organization	
GMDSS	12.03.2000	12.03.2002	1115624; General Operator; St.Petersburg Training Centre	
Radar Observer	10.08.1998	10.08.2001	759; Radar Observation; Kaliningrad’s Training Centre	
ARPA	30.11.1999	30.11.2005	68/99; Baltic Marine Training Centre	
Fire fighting	15.12.1999	15.12.2003	5535/k; Kaliningrad’s Marine College	
Survival	15.12.1999	15.12.2003	5535/k; Kaliningrad’s Marine College	
Personal safety	15.12.1999	15.12.2003	5535/k; Kaliningrad’s Marine College	
First medical aid	15.12.1999	15.12.2005	5535/k; Kaliningrad’s Marine College	
Medical care	15.12.1999	15.12.2004	5535/k; Kaliningrad’s Marine College	
Adv firefighting	15.12.1999	15.12.2006	5535/k; Kaliningrad’s Marine College	

   

6. Medical
	  N 	Date of issue	  Valid till	                                   Issued by	
Health certificate	-	19.02.1999	19.02.2001	Kaliningrad’s Port Hospital	
Yellow fever		10.05.2000	10.05.2010		
Drug/Alcohol test				Included	

  
  7. Personal datas
     Color of Eyes	     Color of Hair	       Height	        Weight	    Complexion	
Brown	Brown	175	70	Normal	

  8. KNOWLEDGE OF LANGUAGES
   (Indicate the level of your languages skills (3 = fluent, 2 = business, 1 = passable, 0 = very limited or none at all)
Language	Speaking	Reading	Written	
English	3	2 	                        2                                            	

				

   9. Marital Status: married 
   10. Family
                             Name	    Relationship	             Occupation	
Svetlana Ivanova	Wife	Homewife	
Anna Ivanova	Daughter	Schoolgirl	
Dmitriy Ivanova	Son	1994	

			

  11. CONFIDENTIAL INFORMATION FOR OFFICE USE ONLY
Full Name of Next of Kin: Svetlana Ivanova 	Relationship: wife 	
Address of Next of Kin: Ivanovskaya Str. 3-7; Kaliningrad, Russia		
Marital Status: married 	Number of Children: 2 	

  
  12. SEA SERVICE (for last 10 years)
Name of vessel	Type	Flag	DWT	Type of Main Engine	Owner’s Name	Rank	  Date 
  From	Date
To	
Sormovskiy42 	G.C.	RUS	3000		ZRP	C.off	11.91	11.92	
Lava	G.C.	RUS	3837		Lava Meritaym Co	Capt	08.95	08.96	

									

									

									

									

									

									

									

									

									

             13.03.2000      
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