29A, Oktyabrskaya str.,Kaliningrad, 236006, Russia Phone: (+74012) 360465 Fax: (+74012)360348 E-mail: [email protected] http://www.green-management.ru/ APPLICATION FORM PHOTO Position applied for: 1 Date available: OS 7/06/2022 (Last Name) Gribanov (First names): Date/place of birth: 05/07/2003 Permanent address: Street: Tobolskaya 35-6 Danila Nationality: Post code: Mailing address: 235006 City: @ E-mail: No.: No.: 89506729648 89506729648 Height (cm): Colour of eyes: Marital status: Nearest airport: Skype address: 186 Green Single khrabrovo Weight (kg): Colour of hair: Father’s name: 75 Blond Education Background School / College From KMFC 19 To 2022 Highest Qualification Attained Navigation department Identity documents DOCUMENT Travel passport: Seaman’s passport Seafarer’s Identity Document Seaman’s book: Country National National National National Number 753557680 MK0337632 Issued date 09.08.2016 09.04.2021 Expiry date 09.08.2026 RUS0501185 31.03.2021 30.03.2026 Do you hold a US Visa ‘C1/D’? Have you been rejected for any visa applied for? If YES, please state the country and reasons Do you hold Schengen visa? YES YES NO + NO + Valid until: YES NO+ Valid until: Place Г.Калининград Морской Порт.Калининград Next of kin Name: Relationship: Address: No.: 5 Kaliningrad City: [email protected] Mobile phone: 4 Rus Street: Post code: 3 1250 Personal details Name: 2 Min salary USD: (Last Name): Semenkova Mother СНТ юбилейный. Цветочная 82 Post code: Home: (First Names) : Natalya City: Mob. Kaliningrad 89506729648 Health Certificates Issue date International Health Cert. Vaccination against Yellow fever Drug & Alcohol test Expiry date 6 Certificates of competency Class / Grade 7 Number Issue date Expire date RUS1525274 Number 16.10.2020 16.10.2025 RUS1520817 20.10.2020 20.10.2025 Fluent Issued by Very good Good Poor + + + Bank account information (optional) Bank Name: Address: Account No.: Swift code: Owner name: Owner address: 10 References (Please give the name and address of your current or immediate past employer) Name of company: Name of person to contact: Address: No.: 10a Expire date Issued at Languages English 9 Issue date Courses attended and certificates obtained Course name Basic safety training (SOLAS) Advance Fire Fighting Elementary First Aid Medical First Aid Medical Care Personal Survival Techniques Personal Safety & Social Responsibility Proficiency In Survival Craft GMDSS ARPA Radar Ship Security Officer Course Seafarers with Designated Security Duties Other: 8 Place / Country Issued References Name of company: Name of person to contact: Address: No.: Satisfactory 11 Sea service 9 Record of previous service (Please give a full record starting with the last vessel on which you served) VESSEL NAME FLAG OWNER NAME VESSEL TYPE Norne Nor General Cargo AtlantNiro Rus Fishing Vessel ## 12 RANK Deck Cadet OS SIGNED ON SIGNED OFF 18.05.202 2 25.04.202 2 30.07.202 1 25.05.202 2 ME TYPE GRT/BHP Required for engineer applicants only Declaration I hereby declare that the above particulars are true and authorise you to contact the referees listed above. In connection with the Law of 29.08.1997 "On Protection of Personal Data" herewith I do agree to the storage and processing my personal data submitted in the company Green Management Sp. z o. o. At the same time I agree to share same with foreign ship owner under the measures aimed at my employment. I am ensured that I have the right to inspect and correct the data. В соответствии с Федеральным законом РФ от 27.06.2006 №152-ФЗ «О Персональных данных», я даю согласие на обработку, трансграничную передачу и хранение указанных в анкете персональных данных, а также персональных данных, представляемых мною при заключении контракта. Оператор обработки данных : ООО «Грин Менеджмент» Цель обработки – добавление ПД в базу данных, предоставление вакансий, трудоустройство . Date: Signature 30.05
