F-CREW-01SEA STAFF APPLICATION FORM – Rev 2.

DATE OF
RANKAPPLIEDFOR: Chief Engineer / Second Engineer 19.03.2021
AVAILABILITY:

1. PERSONAL INFORMATION
FIRST NAME(S): Semen SURNAME: Shurmanov

DATE OF BIRTH: 30.12.1983 PLACE: Astrakhan NATIONALITY: Russian

PLACE OF
PASSPORT NO: 76 3604425 DATE OF EXP: 05.11.2030 Astrakhan
ISSUE:

SEAMAN’S BOOK PLACE OF

MK 0059361 DATE OF EXP:       Astrakhan
NO: ISSUE:

RESIDENTIAL
38 Rzhevskaya Str, Astrakhan. Russia
ADDRESS:

TELEPHONE No -
MOBILE: +7 903 348 09 32
HOME:

EMAIL
sema-83@mail.ru SKYPE ID:
ADDRESS:

2. CERTIFICATE OF COMPETENCY / PROFICIENCY & VALID FLAG ENDORSEMENTS Incl. GMDSS

COUNTRY OF
LIMITED / DATE OF DATE OF COUNTRY OF
CAPACITY LIMITATIONS ENDORSEMENT
UNLIMITED ISSUE EXPIRY ISSUE
CERTIFICATE

Chief engineer Limited 3000kwt 02.03.2018 09.12.2022 Russia      

Second engineer Unlimited 08.09.2020 09.12.2022 Russia      

     

3. TRAINING COURSES
COURSES NUMBER / DETAILS DATE OF ISSUE DATE OF EXPIRY PLACE OF ISSUE

S Basic Training 0834499 14.12.2017 14.12.2022 Astrakhan

T
C FIRST AID CERTIFICATE 0835372 20.12.2017 20.12.2022 Astrakhan
W
PSCRB 0835121 15.12.2017 15.12.2022 Astrakhan

Security-related training 0836435 12.12.2017 12.12.2022 Astrakhan

Proficiency in Designated Security Duties

Shipboard Security Officer (SSO)

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 F-CREW-01SEA STAFF APPLICATION FORM – Rev 2.0

ECDIS

HighVoltage

MLC Compliant Food Handling and Hygiene

Crane Operator Certificate 967 19.09.2014 24.07.2021 Astrakhan

H2S

RADAR OBSERVER

ARPA

BTRM (section A-II/1, A-II/2)

O
T ADVANCED FIRE FIGHTING: A-VI/3 0834778 16.12.2017 16.12.2022 Astrakhan
H
E ADVANCED oil tanker cargo operations 0605424 27.12.2017 27.12.2022 Astrakhan
R
Tanker endorsement ASF202450796 02.03.2018 02.03.2022 Astrakhan

                             

                             

4. PREVIOUS SEA EXPERIENCE Must cover last 5 years, start with your most recent voyage:
VESSEL PROPULSION VESSELOWN AREA OF
TYPE RANK GRT ENGINE TYPE kW FROM TO
NAME TYPE ER OPERATION

CARGO Chief
Mediterranean
RUSICH 11 enginee Diesel 5485 Wartsila 6L20 2280 Rusich Ltd 03.09.2020 20.01.2021
sea
SHIP r

Chief
CARGO
Mediterranean
RUSICH 11 Diesel 5485 Wartsila 6L20 2280 RUSICH Ltd 21.11.2019 10.06.2020
enginee sea
SHIP
r

Chief
SUPLY Caspian sea
C.M. CMI Alpha
Diesel 134 Caterpillar 3516 B 3840 18.03.2019 10.11.2019
GRETA enginee offshore LLC
VESSEL Filanovsky field
r

Chief
Caspian sea
C.M. Cummins KTA 50 CMI Alpha
TUG Diesel 298 2352 20.02.2018 03.10.2018
HEATHER enginee M2 offshore LLC
Filanovsky field
r

Chief
CHEM
VEYSEL Mediterranean
Diesel 2108 Man-6L 28/32 A 1470 ATT LLC" 10.11.2017 25.01.2018
VARDAL enginee Sea
TANKER
r

Chief Caspian sea

C.M. Caterpillar 3412 CMI Alpha
TUG Diesel 134 1000 26.05.2017 31.10.2017
KURIK enginee DI-TA offshore LLC Filanovsky
r field

C.M. TUG Chief Diesel 298 Cummins KTA 50 2352 CMI Alpha 16.03.2017 06.04.2017 Caspian sea

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 F-CREW-01SEA STAFF APPLICATION FORM – Rev 2.0

HEATHER M2 offshore LLC

enginee
Filanovsky field
r

Chief
Caterpillar 3412 Caspian sea
C.M. CMI Alpha
TUG Diesel 134 1000 02.10.2016 23.12.2016
KURIK enginee DI-TA offshore LLC
Filanovsky fied
r

Chief
Caterpillar 3412 Caspian sea
C.M. CMI Alpha
TUG Diesel 134 1000 20.06.2016 25.08.2016
KURIK enginee DI-TA offshore LLC
Filanovsky fiedl
r

Chief
Caterpillar 3412 Caspian sea
C.M. CMI Alpha
TUG Diesel 134 1000 10.02.2016 12.04.2016
KURIK enginee DI-TA offshoreLLC
Filanovsky field
r

Chief
Caterpillar 3412 Caspian sea
C.M. CMI Alpha
TUG Diesel 134 1000 15.07.2014 20.12.2015
KURIK enginee DI-TA offshoreLLC
Filanovsky field
r

Chief Caspian sea

CARGO
RUSICH 7 Diesel Wartsila 6L20 2280 Rusich Ltd 21.02.2014 27.04.2014
enginee Filanovsky
SHIP
r field

OIL Сhief
Mediterranean
LAHTA enginee Diesel 1219 8NVD48-A3U 1192 ATT LLC" 22.10.2013 12.02.2014
Sea
TANCER r

CHEM Chief Caspian-

TOBOL enginee Diesel 1581 Man-6L 28/32 A 1470 21.01.2012 12.07.2013 Mediterranean
TANKER r "ATT LLC" Sea

                                                                 

5. REFERENCESPlease give two previous employers:

Company Name: CMI Alpha offshore Astrakhan Company Name: Azov Trans Terminal

Admiralteiskaya 10 St, app.40Astrakhan

Address: Address: Sovetskya 44A st. app.15-16 Rostov on Don
Russia

Name of Person: Мг. Мuratbek Beineke Name of Person: Mr. Sergey Karpenko

Title: Technical super intendant Title: manager

Phone Number: +7 701 277 77 82 Phone Number: +7 8632 50 29 82

Email technical@cmioffshore.com Email attkadri@donpac.ru

6. LANGUAGES 7. VALID VISAS / VACCINATIONS

LANGUAGE LEVEL VISA / VACCINE EXPIRY DATE

English Intermediate            

                 

                 

8. ENGLISH COMPETENCE CERTIFICATE 9. CLIENT APPROVALS

OVERALL
NAME (e.g., MARLINS) TEST CENTER % APPROVAL (e.g., ARAMCO, ADMA) APPROVAL No
SCORE

Marlins 84            

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 F-CREW-01SEA STAFF APPLICATION FORM – Rev 2.0

                             

                             

10.DECLARATIONSelect YES/NO check boxes as appropriate YES NO

Have you been involved in any marine accident/investigations?
A (Collision/Grounding/Fire/Pollution) If yes please give details. ☐ ☒
     

Have you suffered any accident which rendered you temporarily or partially disabled?
B Ifyespleasegivedetails. ☐ ☒
     

Are you currently under medical treatment or taking medication for existing conditions?
C Ifyespleasegivedetails. ☐ ☒
     

Have you undergone any operations in the last 5 years? If yes please give details.
D ☐ ☒
     

Have you consulted a doctor in the past 12 months for any illness or accident?
E Ifyespleasegivedetails. ☐ ☒
     

Have you suffered, or do you presently suffer from any diseases likely to render you unfit for
F sea service or endangered the health of other persons onboard? Ifyes, pleasegivedetails. ☐ ☒
     

Have you ever undergone psychiatric treatment? If yes please give details.
G ☐ ☒
     

Are you addicted to drugs of any kind or been on the same medication for more than 3 years?
H Ifyespleasegivedetails. ☐ ☒
     

Do you have any criminal convictions or are there any outstanding criminal actions pending
I against you? Ifyes, pleasegivedetails. ☐ ☒
     

11.DECLARATION
I hereby certify that the information given on this form is truthful, complete and correct to the best of my
knowledge.Iunderstand that any false statements or concealment of fact will be grounds for dismissal.

PRINT NAME: S. Shurmanov SIGNATURE: DATE: 19.03.2021

 

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