CMA SHIPS Singapore OPERATIONS MANUAL SECTION 3

Ref: Crew/Form/01a Version: 01/07/2015 PAGE 1 of 1

TITLE: APPLICATION FORM

APPLICATION FORM
RECENT
PHOTO

ADD NAME AND ADDRESS OF RECRUITING AGENCY

Position applied for: 3rd Officer

Type of vessel:
Availabibity date: Asap

Are you responding to a media advertisement? NO

If YES, please state which one

Are you applying upon personal or professional recommendation? NO

If YES, please state who

Surname: Mel First name: Serhii

Other names Known as Dmytrovych Nationality: Ukrainian

Place of birth: Nova Kakhovka Kherson Region Date of Birth: 26/05/2002 Age: 20

Passport
Number Place of issue Date of issue Date of expiry Issuing Authority

FV979377 Kherson 01.08.2019 1/8/2029 6512

Visas
Type Number Place of issue Date of issue Date of expiry
C1/D (USA)
C1 (USA)
D (USA)
Australia Entry visa
MCV (Australia)
Schengen

Education Background
School / College From To Highest qualification attained
Maritime College of Kherson State Mari 01.09.2017 01.07.2021 Navigator

Personal details
Full address:
Wroclaw,Semaforowa 34/1

Postal code: 52-115 Country: Poland

E-mail: Sergeymel11@gmail.com

Home tel number:

Mobile phone: +380951118657

Domestic Airport Wroclaw, Poland International Airport Wroclaw, Poland

Marital status: Single

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Full name of Next of Kin: Arnaut Tetyana Petrivna Relationship Mother
Address of Next of Kin if
different from above
Phone
+380958772474
if different from above:

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Dependents
Name Date of birth Age Gender Relationship

Person to contact in case of emergency

Name: Arnaut Tetyana Petrivna Relationship Mother

Address: Ukraine, Lviv region, Noviy Rozdil

Phone number: Mobile number: +380958772474

National Seaman's Book

Number Place of issue Date of issue Date of expiry Issuing Authority

AB657935 Kherson 04.06.2019 04.06.2019 Port of Kherson

National Certificate of Competency (COC)- Licences

Grade Issuing Authority Number Date of issue Date of expiry Place of Issue Date revalidated
State Service for
Maritime and
Navigator 01489/2021/11 25.08.2021 01.07.2026 Kherson 25.08.2021
River Transport of
State Service for
Ukraine
Maritime and
Endorsement 01489/2021/11 27.08.2021 01.07.2026 Kherson 27.08.2021
River Transport of
Ukraine
National GMDSS & Endorsement
Issuing Authority Number Date of issue Date of expiry Place of Issue
State Service for Maritime and River
01187/2021/11 22.06.2021 14.06.2026 Odessa
Transport of Ukraine

Medical Fitness Certificate

Type Date of issue Date of Expiry

Yellow Fever Vaccination

Date of Issue Date of Expiry
P3L241V 18.06.2020 -

Foreign languages other than English

Level:
Language
Beginner Intermediate Advanced
Ukrainian []
Russian []

Medical History
Have you ever signed off from
No If yes give details
a ship due to medical reasons?
Name of vessel Date of Occurrence

Brief description of Illness or Injury

Other personal details

Height: 187 Weight: 75 Colour of Hair: Brown

Colour of eyes: Brown Safety shoes size: 43-44 Boiler suit size: M

Uniform Shirt size: L Uniform Trousers size: M

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Details of other Marine courses
IMO model
Type of Marine Course Reference- Regulation Number Date of issue
course
1.19 - 1.20 1.13 - STCW Reg.
Basic Training 1.21 A-VI/1-1 to A-VI/1-4 12303 01.10.2018

Personal Survival STCW Reg. A-VI/1-1

1.19
Techniques

BASIC TRAINING
STCW Reg A-VI/1-2
Basic Fire Fighting 1.20

STCW Reg A-VI/1-3

Elementary First Aid 1.13

Personal Safety & Social STCW Reg A-VI/1-4

Responsibilities (Human 1.21
Relationship)

STCW Reg A-VI/2 par 1.3

Proficiency in survival craft & Rescue Boats 1.23 170957 21.07.2020
STCW Reg A-VI/3
Advanced Fire Fighting 2.03 002737 25.02.2020
STCW Reg A-VI/4-1
Medical First Aid 1.14 002374 25.02.2020
STCW Reg A-VI/4-2 par 2
Medical Care 1.15
STCW Reg II/2
ROP/ARPA 1.08 1344958 18.06.2021
STCW Reg II/1
ARPA / NCC 1.07

Radar Simulator
STCW Reg II/1 par.2.5
ECDIS 1.27
US 49 CFR 172.700-172.204
HAZ MAT
STCW Reg
Ship simulator bridge teamwork 1.22 II/1

BTM / ETM
STCW Reg VI/5 / ISPS Code
Ship Security Officer (SSO)

BASSnet
STCW Reg II/1 & II/2
Ship handling & manoeuvring
STCW Reg VIII/2 US33CFR
Bridge resource management 157.415

Loading software (name it)

Large Vessel Handling Simulator / CMA CGM

Engine Room Simulator

Indos Number

Upgradation Course

Revalidation Course for renewal of CoC

High Voltage Training

Reefer Training

Engine Maker’s Training

Crane Manufactures training

ISPS code
Vessel security training course 2735/30021946 18.02.2019
IMO Assembly Res A741(18)
Ship Safety Officer
UK MCA
ISF Marlins English test

Designated Security Duties 2889/30021912 18.02.2019

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Training of candidates for all general di 1335034 07.06.2021

Flag State Documents

Document Grade Number Place of Issue Date of Issue

Malta:

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 RECENT
PHOTO

Male

Issuing Authority

12

Date of expiry

roclaw, Poland

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 Relationship

380958772474

Issuing Authority

Port of Kherson

Date expiry

01.07.2026

27.08.2021

Place of Issue

Odessa

piry

piry

Advanced
[]
[]

If yes give details

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Date of expiry

01.10.2023

19.06.2025

04.05.2025

04.02.2025

18.06.2026

18.02.2024

18.02.2024

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07.06.2026

Date Expiry

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Employment history (at least the last 5 years)

Vessel * Company Manning Agent Trading area Vessel Flag DWT / TEU Year Main Engine Position Sign on Sign off Total Reason
type built date date mm/dd for
** leaving
Make Type KW
***
D/P Kherson Sea
m/v “Kiliya” Kherson Sea Commercial Port
Ukraine, Dnipro river, Black Sea GC Ukraine 2157 tonnes 1966 Deck Cadet 04.07.2019 31.07.2019 00/27 EOC
Commercial Port

m/v “Profit” LLC “Profit Ships” Kherson Sea Commercial Port

Ukraine, Dnipro river, Black Sea GC Ukraine 1334 tonnes 1972 Deck Cadet 13.04.2020 03.07.2020 02/20 EOC

m/v “PMS PMS EDELWEISS

Eurocrew Worldwide BC Marshall Islands 57 893 tonnes 2013 MessMan 27.07.2020 20.09.2020 01/24 EOC
EDELWEISS” Shipping Co.
m/v “PMS PMS EDELWEISS
Eurocrew Worldwide BC Marshall Islands 57 893 tonnes 2013 Deck Cadet 21.09.2020 21.02.2021 05/00 EOC
EDELWEISS” Shipping Co.

m/v “Profit” LLC “Profit Ships” Kherson Sea Commercial Port

Ukraine, Dnipro river, Black Sea GC Ukraine 1334 tonnes 1972 Deck Cadet 25.03.2021 23.05.2021 01/29 EOC

m/v “Rego” Atlantic Bulk AS. Eurocrew Worldwide BC Marshall Islands 58 729 tonnes 2009 Ordinary Seaman 18.09.2021 22.07.2022 10/02 EOC

* or industry sector if ashore

** Use abbreviation: PC = Pure container, GC = General Cargo, BC = Bulk Carrier, LNG = Tanker, LPG = Tanker, Chem = Chemical, RoRo = Roll on Roll off
*** Use abbreviation: MR = Medical Reason, VS = Vessel Sold, EOC = End of Contract

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Summary of Experiences (in number of years)
Years as/
Container Tanker Bulk carrier Roro others (Please state)
on
Master -
C/E
C/O - 2/E

2/O - 3/E

3/O - 4/E

E/O

Total

Years as/ Sulzer Sulzer SEMT Steam

B&W MAN others
on RTA RND Pielstick Turbine
C/E

2/E

3/E

4/E

E/O

Total

References
Do you have any objection if we will contact your last employers for
Yes/No No
reference?
If YES please specify why:
If NO please specify below:

Please give the name and address of your current or immediate past employer
Name of company Eurocrew
Name of person to
contact
Address Ukraine, Odessa, Lane Sabansky 3, office 10-H

Tel number +38 (048) 235-90-59

Please list two contactable referees or past employers

Name of company Eurocrew
Name of person to
Natalya Olexandrivna
contact
Address Ukraine, Odessa, Lane Sabansky 3, office 10-H

Tel number +380675221355

Name of company Eurocrew

Name of person to
Valentina
contact
Address Ukraine, Odessa, Lane Sabansky 3, office 10-H

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Tel number +3800675892684

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Bank details
Bank
Privat Bank Sort code: 305299
name:
Branch
JSC CB PRIVATBANK Swift name: PBANUA2X
name

1D HRUSHEVSKOHO STR., KYIV,

Address: IBAN number: UA853052990000026200888552517
01001, UKRAINE
Account
Account
name/ Serhii Mel 4731219612058190
number:
Title

I hereby affirm that all the information provided by me in this application is true and correct to the best
of my knowledge and belief; further, that no Certificate of Competency or License issued to me has
ever been revoked or suspended. I also certify that my medical history contained abocve is true and
any false statement or undisclosed material information about past illness or injury will disqualify me
from any employment benefits and claims.

Date_____________
___ Signature_______________________

* The company may contact my previous employer for references.

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