“DOBROFLOT LLC”

Crew Agency
E-mail: dobroflot-crew@mail.ru; info@dobroflot-crew.ru Tel: +7-978-586-85-62 Skype: Crew Dobroflot

SEAFARER’S APPLICATION FORM

MAIN INFORMATION
Position desired: cadet Alternative position: -
Date of readiness: always Salary desired: 700$
Full name:Kuzin Vadim Vladislavovich Please attach your
Date of birth: 28.08.200 Nationality: Russian photo to e-mail message
3 and send with this
Place of birth: Russia, Krasnodarskiy Krai, Novorossiysk Application form

Mob.: 89883408762 Tel: 89883408762

e-mail: kuzin.vadim08@gmail.com Skype: -
Home address:Novorossiysk, Spetsmorstroevskaya street 7a
Marital status Single Kuzin Vladislav Relation: -
(Single, Married, Stanislavovich
Tel: 89887704889
Divorced, Next of kin
Widower) (Full name):
Number of - Address: Spetsmorstroevska
Children: ya 7a
BIOMETRICAL DATA
Height (cm): 189 Colour of Black Overall Size: 52
Hair:

Weight (kg): 94 Colour of Green Shoes Size: 54

Eyes:

ADDITIONAL INFORMATION
English ability: Fluent ☐ Very Good ☐ Good ☐ Basic \/ Poor ☐
Other languages: No
Extra skills / YES NO ISSUING AUTHORITY Date Issued Expiry Date
certificates:
Welder (type of -
welding)
Fitter -
Turner -

EMPLOYMENT HISTORY:
(starting from the last contract)
№ Ship’s Name Ship’s Owner/ Vessel type Engine From
Year of Management type Rank
built DWT HP To
Flag Crewing Agency

1
 1

EDUCATION BACKGROUND:
School or Academy name From To Highest Qualification Obtained
Ushakov Maritime College Novorossiysk No

IDENTITY DOCUMENTS:
Documents Number Issued Place of issue Expire
:
Seaman’s Book:
USA Visa:
Schengen Visa:
PANAMA,
LIBERIA and other

HIGHEST CERTIFICATES OF COMPETENCY and STCW CERTIFICATES:

Licenses and Certificates Number Issued Place of Expire
Issue
Certificate Of Competency / License:
Endorsement Of Certificate:
GMDSS:
Endorsement for GMDSS:
Basic Safety training A-VI/1-1
Proficiency in Survival Craft and Rescue
Boats A-VI/2-1
Proficiency in Fast Rescue Boats A-VI/2-2
Advanced fire fighting A-VI/3-1
Medical first aid A-VI/4-1
Medical care A-VI/4-2

2
Ship Handling Arrangements A- II/2
ECDIS (Deck Officers)
Radar and ARPA observed (operational)
A- II/1
Radar and ARPA observed
(management) A- II/2
Carriage of dangerous and hazardous
subst.
Bridge/ Engine resources management
Training of Ship Security Officers SSO
(ISPS Code)
Electrical and electronic engineering
Tanker familiarization course A-V/1, 2-7
Other certificates:

FLAG DOCUMENTS and OTHER COUNTRIES SEAMAN’S BOOKS:

Country Number Document type Issued Expire

Medical Number Issued Place of issue Expire

examination
Yellow Fever

I hereby confirm that all the information provided by me is true and correct:
Yes

Date: Applicant’s name and signature:

Crew manager’s remarks: