CMA SHIPS Singapore OPERATIONS MANUAL SECTION 3

Ref: Crew/Form/01b Version:01/07/2015

TITLE: APPLICATION FORM FOR CADETS

CADET APPLICATION FORM

ADD NAME AND ADDRESS OF RECRUITING AGENCY

Position applied for Client Vessel * : Container

Availabibity date: Oct-22
* : For RTO, indicate the proposed vessel and, availability Date and planned duration

Are you applying upon personal or professional recommendation? YES

If YES, please state who Mykyta Kozhemiako

Surname: Karabinienko First name: Aleksandr

Other names Known as Nationality: Ukranian

Place of birth: Odessa Date of Birth: 14.04.2000 Age:22 Male

Passport
Number Place of issue Date of issue Date of expiry Issuing Authority
FS287428 Odessa 22.08.2018 22.08.2028 5116

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

Education Background
Nautical School / College / University From To Highest qualification attained
Odessa Maritime Academy 2018 2022 Bachelor`s Diploma

Personal details
Full address:
Davida Oistraha6 108

Postal code: 65125 Country: Ukraine

E-mail: sashakarabinenko@gmail.com

Home tel number:

Mobile phone: 380976177404

Domestic Airport International Airport Odessa International Airport

Marital status: single

Full name of Next of Kin: Karabinienko Olga Aleksandro Relationship mother

Address of Next of Kin if
Davida Oistraha6 108
different from above
Phone
380984405625
if different from above

Dependents
Name Date of birth Age Gender Relationship

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Person to contact in case of emergency
Name: Karabinienko Olga Aleksandrovn Relationship mother

Address: Davida Oistraha6 108

Phone number: 380984405625 Mobile number:

National Seaman's Book

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

0207375 Odessa 18.09.2019 18.09.2024 Port Odessa

National Cadet Diploma

Grade Issuing Authority Number Date of issue Date of expiry Place of Issue Date revalidated Date expiry

Medical Fitness Certificate

Type Date of issue Date of Expiry

Yellow Fever Vaccination

Date of Issue Date of Expiry
10.02.2021

Foreign languages other than English

Language Level:
Beginner Intermediate Advanced

Personal details
Height:182 Weight: 60 Colour of Hair:Brown

Colour of eyes: brown Safety shoes size:41.5 Boiler suit size:m

Uniform Shirt size:m Uniform Trousers size: m

Details of other Marine courses

IMO model
Type of Marine Course Reference- Regulation Number Date of issue Date of expiry
course
1.19 - 1.20 1.13 - STCW Reg.
Basic Training 1.21 A-VI/1-1 to A-VI/1-4 18924 13.12.2018 13.12.2023

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

1.19
Techniques
BASIC TRAINING

STCW Reg A-VI/1-2

Basic Fire Fighting 1.20 255154 02.02.2021 02.02.2026

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 255264 03.02.2021 03.02.2026

STCW Reg A-VI/4-1

Medical First Aid 1.14

STCW Reg A-VI/4-2 par 2

Medical Care 1.15

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Employment history
Vessel * Manning Agent Vessel type ** Flag Position Sign on date Sign off date Total mm/dd

* 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

Regional Training Officer 's Selection Criteria

Level of English Writing : Speaking :

VOA / Pre Employment Test result :

Cadet details, Diploma and Certificates posting into MAP Yes No

Assessed potential of the Cadet :

Date Place Signature

Cadet's commitment to follow CMASHIPS training monitoring program

I, undersigned Karabinenko Aleksandr certified that I received detailed information to the CMASHIPS Cadet Training Monitoring Program

and I received a copy of the CMASHIPS Cadet Guide which was presented and fully explained.

I certify that I will comply to the Cadet training program under supervision of the Traing Officers on board and ashore.

Date 30.08.2022 Place Odessa Signature

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