Application

Form
1 CONTACT DETAILS (Enter Details)

RANK AB/ Rigger Postal Address Gregora -2a, flat 36A.

Riga,Latvia. LV-1083
DEPARTMENT Deck/Engineer/Ratings Deck

Title Mr/Mrs/Ms/other (Specify) Mr

First Names Arturs Country of Latvian

Residence
Surname Masurevskis Nearest Riga Rix

Station/Airport
Nationality Latvian Tel No P1 0037120383646

1
Place of Birth Rezekne Tel No P2

2
Country of Birth Latvia Fax No P3

Country of Latvian E Mail P4 artikmuh@inbox.lv

Residence
2 AVAILABILITY (Enter Details)
Date Available 20.02.2020 Date Available To unlimited

From
3 BANK DETAILS (Enter Details)
Bank Name Luminor DNB Bank Sort Code

Bank Address Bank Account No LV27RIKO0001050345107

Skanstes iela 12,Riga,LV1013
Bldg Soc Ref No (if

appl)
Account Holder’ s
Name
National Insurance
No
4 NEXT OF KIN DETAILS (Enter Details)
NOK Name Olga Masurevska NOK Address Krasotaju-24,Rezekne,Latvia

NOK Relationship Mother

NOK Tel No 0037126633917

5 CERTIFICATE OF COMPETENCY (latest only) (Enter Details) (Please include copies for our records)

Details Issue Date Expiry Date Country Limitations, Certificate

Able seafarer deck 18.102022 17.10.2027 latvia 3092/22

LSC Marine training 16.02.2009 latvia 031310

6 ENDORSEMENTS (Enter Details) (Please include copies for our records)

Cod Details Issue Date Expiry Date Country Limitations, Certificate

e of Issue No’ s etc

ED0 DCE ’ Petroleum

1 DCE ’ Gas
ED0
2 DCE ’ Chemical
ED0

Form Name: QFM 06

Issue Date:
10/09/2015
Revision Status:
5
 3
7 TRAVEL DOCUMENT CHECK LIST (Enter Details) (Please include copies for our records)
TV0 Seamans Book 20.03.2019 20.03.2029 Latvia 0271458

2 TV0 Passport 21/01/2014 20/01/2024 latvia LV4595393

3
TV0 UK Work Permit (if 07/04/22 07.04/27 Uk WE-SW2T372-NT
4 applicable)
TV0 US Visa 17/09/2014 15/09/2019 latvia 20142583880013

5 Travel ’ Other ’

Cod Details Issue Date Expiry Date Country Limitations, Certificate

e of Issue No’ s etc

TV0 Discharge Book

8 MEDICAL DOCUMENT CHECK LIST (Enter Details) (Please include copies for our records)

Code Details Issue Date Expiry Country of Issue Limitations, Certificate No’ s etc

Date
MD01 Chester step Fitness 28.02.2023 28.02.2024 Latvia 2012/1774
MD02 OGUK Medical Fitness 28.02.2023 28.02.2025 Latvia OGUK/2012/1774

Medical ’ Other ’ medical sertificate 28.02.2023 28.02.2025 latvia AE60227

Medical ’ Other ’ drug and alcohol 28.02.2023 28.02.2024 Latvia 500/23

9 TRAINING CHECK LIST (Enter Details) (Please include copies for our records)

Code STCW95 Certification Details Issue Date Expiry Date Limitations, Certificate No’ s etc

TP15 Personal Survival Techniques (PST)

TP07 Fire Prevention & Fire Fighting 03.03.2021 03.03.2026 80b-019/21

TP04 Elementary First Aid 03.03.2021 03.03.2026 80b-019/21

TP14 Personal Safety & Social Responsibility (PSSR) 03.03.2021 03.03.2026 80b-019/21

TP01 Advanced Fire Fighting 03.03.2021 03.03.2026 80b-019/21

TP08 Medical Care

TP09 Medical First Aid

TP13 Proficiency in Survival Craft & Rescue Boats (PSC&RB) 20.10.2022 20.10.2027 80a-657/22

TP06 Fast Rescue Craft 15/09/2015 15/09/2020 54-043/15

TP05 Engine Room Watch Rating Certificate

TP12 Navigational Watch Rating Certificate 18/10/2022 17/0/2027 3092/22

STCW95 ’ Other ’ training for passenger ships 10/11/2020 10/11/2025 82-075/20

personnel 24/03/2014 unlimited 74-612/14

STCW95 ’ Other ’ designated security duties
STCW95 ’ Other ’

Code STCW78 Certification Details Issue Date Expiry Date Limitations, Certificate No’ s etc

TN01 Basic Sea Survival

TN07 Ship Captain’ s Medical

TN05 First Aid at Sea

Form Name: QFM 06

Issue Date:
10/09/2015
Revision Status:
5
 TN09 Stage II Fire Fighting (4 day)

Code Other Certification Details Issue Date Expiry Date Limitations, Certificate No’ s etc

TS12 GMDSS ’ General Operator Certificate

TS13 GMDSS ’ Restricted Operator Certificate

TS30 ISPS ’ Ship Security

Other ’ GWO slinger signaler banksman Rigger 05/07/2022 Unlimited AM099996LV

Other ’ GWO basic safety training 5.module 01/07/2022 01/07/2024 AM099996LV

Other ’

Other ’

TN08 Stage I Fire Fighting (2 day)

TN06 Navigation Control (NCC)

TN04 Electronic Navigational Systems (ENS)

TN03 Proficiency in Survival Craft (CPSC)

STCW78 - Other -

STCW78 ’ Other ’

STCW78 ’ Other ’

Code OFFSHORE Certification Details Issue Date Expiry Date Limitations, Certificate No’ s etc

TR01 Offshore Survival (OPITO) BOSIET 10/08/22 09/08/26 5719

TR07 HUET 10/08/22 09/08/26 With+ce ebs (5750)

OPITO ’ Other ’

OPITO ’ Other ’

Form Name: QFM 06

Issue Date:
10/09/2015
Revision Status:
5
10 SEA EXPERIENCE (Previous Sea Experience – Earliest Date First)

Name:

Date From Date To Rank Ship Name GT Company Vess

01/05/2009 02/10/2009 OS Atlantic spirit 62775 interorient Oil tanker

29/11/2019 23/04/2010 os Baltic marshall interorient Oil/chem tanke

15/05/2017 03/07/2017 ab balmoral 73576 Clyde marine Pasanger cruis
15/06/2010 11/10/2010 Ab fedor 41397 csm Oil/chem tanke
15/07/2017 03/08/2017 ab balmoral 73576 Clyde marine Pasanger cruis
28/11/2010 25/03/2011 Ab Sks spey 81380 csm Oil crude tanke
11.08.2017 12.10.2017 Ab Ulysses 50938 Matrix Ro-pax
16/07/2011 19/10/2011 Os/painter Great swan 14332 lsc Chemical tank
13/11/2017 11.01/2018 Ab Ulysses 50938 Matrix Ro-pax
19/11/2011 25/01/2012 Ab mercia 29429 lsc Ro-ro
08/02/2018 12/04/2018 Ab Ulysses 50938 Matrix Ro-pax
30/04/2012 16/10/2012 Ab Northern light 30053 hmm Oil chem /tank
10/05/2018 02/07/2018 Ab Ulysses 50938 Matrix Ro-pax
21/03/2013 04/07/2013 Ab Northern light 30053 hmm Oil chem/tanke

28/03/2014 19/08/2014 Rigger Ab Ouro do brasil 15218 Candina baltic Fruit juice tank

26/10/2014 03/01/2015 Rigger Ab Ouro do brasil 15218 Candina baltic Fruit juice tank

16/03/2015 23/04/2015 ab enterprise 3784 osm General cargo

13/05/2015 28/07/2015 ab Fionia seaways 25609 osm Ro-ro

23/09/2015 16/12/2015 Rigger /ab Wind perfection 22161 Crewplanet Floating hotel

09/02/2016 28/04/2016 ab Leopard moon 29939 lsc Oil/chem tanke

17/07/2016 28/08/2016 ab European endeavour 22152 Clyde marine Ro-pax

22.09/2016 11/10/2016 ab Leopard sun 29939 lsc Oil chem/tanke

05/11/2016 29/12/2016 ab European endeavour 22152 Clyde marine Ro-pax

28/01/2017 26/03/2017 ab European endeavour 22152 Clyde marine Ro-pax

Form Name: QFM 06

Issue Date:
10/09/2015
Revision Status:
5
 En

018 Ab Ulysses 50938 Matrix Ro-pax 15713

018 Ab Ulysses 50938 Matrix Ro-pax 15713

019 ab Ulysses 50938 matrix Ro-pax 15713

019 Ab Ulysses 50938 Matrix Ro-pax 15713

019 Ab Ulysses 50938 Matrix Ro-pax 15713

019 Ab Ulysses 50938 Matrix Ro-pax 15713

020 Ab Ulysses 50938 Matrix Ro-pax 15713

020 ab Ulysses 50938 matrix Ro-pax 15713

021 Ab Scandia seaways 60465 Osm RO-RO 23600

021 Ab Petunia 2007 Osm RO-RO 23600

021 Ab Stena SCANDICA 35456 Clyde marine Ro-Pax

2021 Rigger GEOSURVEYOR-X Lx6z Boreas Hsc

021 Rigger GEOSURVEYOR-X Lx6z Boreas Hsc

021 Rigger NP289 Helder maritiem Multipurpose barge

021 Rigger/ab MTS Valiant Helder Maritime Anchor handling tug

022 Rigger NOORDSTROOM Helder Maritime Anchor handling tug

022 AB/COOK Pieter CALAND IPS Hooper barge 3.241

022 Ab/cook JOHANNIS DE RIJKE IPS Hooper barge 869

022 Ab/cook Jan LEEGHWATER IPS Hooper barge

Form Name: QFM 06

Issue Date:
10/09/2015
Revision Status:
5
25/10/22
13.07.2022
22/11/22
03.08.2022 RIGGER/
Ab/cook AB ZP
DCVbulldog
BALDER IPSBOLUDA
IPS/ /HEEREMA Deepwater
Habor Tug
constructio
23.08.2022 31.08.2022 Ab/Rigger Zp Boxer IPS/ BOLUDA AHTS
13/12/22 22/12/22 Ab Hanson Thames Clyde marine Dreger
14/09/2022 12/10/2022 Ab/Rigger VB BRENT IPS /Boluda AHTS
09/01/23 21/02/23 Ab/Rigger Manta Boskalis / Tos Ahts

08/04/23 09.05.23 Rigger Svanen Van Oord/Ips Heavy lift

05/06/23 04.07.23 Rigger Svanen Van Oord/Ips Heavy lift
10.07.23 08.09.23 Ab Flinstone Deme/select off shore lpipe burn
12.08.23 23.08.23 Rigger THIALF Ips/ Herrema Deepwate
construct
24.08.23 13.10.23 Tower Cf Explorer Taylor Hopkinson/Deme Walk to W
Rigger

Form Name: QFM 06

Issue Date:
10/09/2015
Revision Status:
5
11 PLEASE USE THIS BOX TO INCLUDE ANY ADDITIONAL INFORMATION RELEVANT TO YOUR APPLICATION

•Cheery picker exspierence

● Type:Semi submersible crane Vessel •Monopile installation,cable cover remove. Bubble box instalation, bottom plug ,top plug
●Mobillisation/presentation FJLT for instalation project: Baltic eagle ) diskonection. HPU highe pressure hoses.
●Preparation installation WTG JACKETS. • conection, diskonection hammer
●Pin piles installation • cable pull in tower full installation, hang off cover, lifting procedures
●Installation TP COVER. NNG PROJECTS
●Heavy lifting procedures
●In charge of radio communication coverage
●Ahts exspierence: anchor handling,
Main operation with sweeper for a winches and special equipment,conection diskonection Lifting
equipment chains shackles inspection mooring operation.
Working at heigh procedures,in charge of radio communication coverage.
●
●crane exspierence 30 tons ,mobile crane
● working assist with ROV
●good cooking skill

12 EQUAL OPPORTUNITIES POLICY

Please tick the box if you have completed and enclosed the Equal Opportunities Policy monitoring form

13 REFEREES (Enter Details)

REFERENCE 1 ’ Can we take up this reference NOW / LATER? REFERENCE 2 – Can we take up this reference NOW / LATER?

Title Title

First Names First Names

Surname Surname

Address Address

Post Code Post Code

Tel No Tel No

Fax No Fax No

Form Name: QFM 06

Issue Date:
10/09/2015
Revision Status:
5
I confirm that the details given are to the best of my knowledge accurate and true, that I am in legal possession of the above qualifications and
certificates. Furthermore, I confirm that I have no unspent criminal convictions and I agree that my personal record can be verified with the Criminal
Records Bureau should this be deemed necessary. I also agree that my details will be shared between Clyde Marine Recruitment regional offices,
and I may be contacted by either office regarding employment.

Signature: ____________ ____ Date: ________________

Form Name: QFM 06

Issue Date:
10/09/2015
Revision Status:
5
 Form Name: QFM 06
Issue Date:
10/09/2015
Revision Status:
5