A 201/202/203, City point J.B.

Nagar , Andheri Kurla Road, Andheri (East) Mumbai – 400 059

Tel.: +91 22 – 4037 2222, 4050 2100 - Fax : +91 22-2823 4987,4050 2150,
E -mail mumbai@damicoishima.com, hrsea@damicoishima.com

APPLICATION FORM / PERSONAL DATA UPDATE FORM

RANK APPLIED 111: Ch. Mate DATE OF APPLICATION 27/09/22

INDOS NUMBER DATE OF AVAILABILITY 28/09/22

1. PERSONAL DETAILS
SURMAME FIRST NAME MIDDLE NAME
Igor
NAME Liskevych
Date of Birth 23/02/87 Place of Birth Ukraine Nationality 022: UCRAINA
Permanent Address 51 apt. 24/3 Zatonskogo str. Odessa Present Bucharest, Romania

City Odessa City Romania

Zip Code 65100 Zip Code
Mobile
Telephone NA +380963760857
Skype ID
E- mail 1 foxdiego10987@gmail.com Igor Liskevych
ODS: ODESSA, UKRAINE -
Home airport
CENTRAL

2. PASSPORT DETAILS
DATE OF DATE OF
NUMBER PLACE OF ISSUE
ISSUE EXPIRY
PASSPORT FH848824 12/09/17 12/09/27 Ukraine
US C1/D VISA 20181425820007 23/05/18 21/05/28 Ukraine
YELLOW FEVER NA 18/04/16 NA Ukraine
SHENGEN VISA No
OTHER VISA No

3. SEAMAN BOOK (S)

DATE OF DATE OF
NUMBER PLACE OF ISSUE
ISSUE EXPIRY
NATIONAL AB687555 21/01/22 21/01/27 Ukraine
OTHERS
OTHERS

4. ACADEMIC QUALIFICATIONS
FROM
GRADE TO (YEAR) DEGREE
(YEAR)
SCHOOL 1993 2002
COLLEGE Maritime college of Technical fleet 2002 2006 Navigator
PRE- SEA
TRAINING ONMA 2014 2017
INSTITUTE Deep sea Navigator

5. LICENCE / CERTIFICATE OF COMPETENCY

Date of Date of
Number Date of Issue STCW 95/2010
Grade Expiry Revalidation
YES
NO
PANAMA
MALTA
LIBERIAN Chief Mate 1100903 25/06/18 06/06/23 yes
ITALIAN
LUXEMBOURG
SINGAPORE
MARSHALL
ISLANDS
OTHERS
DSIPL/ MANN-8.5/01-01 17 DEC 2020 REV-1
6. STCW AND OTHER CERTIFICATES
Issuing
Date of Date of
STCW Courses Certificate No. Authority/ Place of Issue
Issue Expiry
INSTITUTE
PSSR

EFA

MFA (First Aid) 9735 22/08/19 22/08/24 Mortelecom Odessa

MEDICARE 71 17/05/18 17/05/23 Mortelecom Odessa

PST

PSCRB (Survival Craft) 12858 22/08/19 22/08/24 Admiral Odessa

BASIC FIRE FIGHTING

ADVANCE FIRE F. 11420 22/08/19 22/08/24 Admiral Odessa

ROC

ARPA 30 18/05/18 18/05/23 Mortelecom Odessa

GMDSS 12561/2014/01 17/12/14 Odessa

GMDSS NAT.END 12561/2014/01 16/09/19 04/09/24 Odessa

ARPA NAV. SIM COURSE

SMS/NAV CONTROL/SHIP HANDLING

01B: CHIEF MATE

SIMULATOR TRAINING

ENGINE SIMULATOR

BTM 0151/2018 18/05/18 18/05/23 OMTC Odessa

ECDIS
ECDIS DANALEC

ECDIS SPERRY

ECDIS TRANSAS

ECDIS FURUNO TE32891 08/06/18 NavSkills Odessa

ECDIS KEIKI TOKYO

ECDIS JRC

OTHER TYPE OF ECDIS

ICE CLASS COURSE

POLAR BASIC

POLAR ADVANCED

BRM
MARINE ELECTRICAL/ELECTRONIC
COURSE

ENGINE ROOM TEAM MANAGEMENT

TYPE SPECIFIC COURSES

RORO PAX
TANKER FAM. (OIL)
TANKER FAM.(CHEM)

TANKER FAM.(GAS-CHEM-OIL)

SPEC. TANKER SAFETY

SPEC. CHEM TANKER SAFEY

REF OIL

REF CHEMICAL

DCE PETROLEUM

DCE CHEMICAL

L.C.H.S.

OTHER COURSES
LEADERSHIP AND TEAMWORK
OPERATIONAL
LEADERSHIP AND TEAMWORK
MANAGEMENT
HIGH VOLTAGE BASIC

HIGH VOLTAGE ADVANCED

Safety Officers Cert ( SOC)

HAZMAT 1653 27/03/19 27/03/24 Mortelecom Odessa

WELDING 2G,3G,6G

SSO 4477 21/08/19 21/08/24 Mortelecom Odessa

DESIGNATED SECURITY DUTIES

ACC/INC INVESTIGATION

DP BASIC

DP ADVANCED

FULL DP

SECURITY AWARENESS

HACCP
CYBER SECURITY
MARITIME ENGLISH
 7. SEA EXPERIENCE: (Most recent first)
VESSEL MAIN ENGINE PERIOD
REASON
COMPANY YEAR FOR
NAME TYPE DWT GRT RANK MAKE MODEL BHP UMS FROM TO M/D SIGN-OFF
BUILT
004: Bulk End of
Vita Maritime Christine Oldendorff 93000 51239 2010 111: Ch. Mate 22/06/20 03/04/21 9 M 12 D
Carrier Contract
004: Bulk End of
Vita Maritime Diana Schulte 80000 43506 2010 113: 2nd Mate 15/04/19 04/08/19 3 M 20 D
Carrier Contract

004: Bulk End of

Vita Maritime Diana Schulte 80000 43506 2010 113: 2nd Mate 26/07/18 15/12/18 4 M 19 D
Carrier Contract

004: Bulk End of

Vita Maritime Christine Oldendorff 93000 51239 2010 113: 2nd Mate 17/12/17 28/04/18 4 M 11 D
Carrier Contract
004: Bulk End of
Vita Maritime Boavista 93000 51239 2010 113: 2nd Mate 13/02/17 26/07/17 5 M 13 D
Carrier Contract
004: Bulk End of
Vita Maritime Boavista 93000 51,239 2010 113: 2nd Mate 28/04/16 16/10/16 5 M 18 D
Carrier Contract

Any Major Incidence / Observation / Special Experience for reporting:

 8. REFERENCES
(Please give two references/companies whom we can ask about your seagoing experience)

Name Company/ Designation Telephone / Contact No.

1. Anna Leschuk Vita Maritime +380 50 490 5082

2.

REMARKS:
8A. REF. CHECK YES/ NO

9. NEXT OF KIN / FAMILY PARTICULARS

NAME Liskevych Tatyana RELATION Wife

ADDRESS Same address

DATE OF
NAME D.O.B PP/NO. VALIDITY ISSUED
ANNIVERS

WIFE Liskevych Tatyana 16/07/87 16/12/11

CHILD (M/F) Liskevych Egor 26/01/13

CHILD (M/F) Liskevych Gleb 04/03/22

10. HOW DID YOU COME TO KNOW ABOUT US? (Please tick the appropriate medium) þ

A Company presentation/seminar B Marine Club notice-board C Marine magazine advertisement

D Newspaper advertisement E Told by seagoing friend (s) F Direct Mail from Company

G Relatives working in the Company H Other (Please Specify)

11. DECLARATION
I declare that the information given by me in filling up this from to the best of my knowledge are true and complete. I also declare that
the documents submitted to D’AMICO SHIP ISHIMA INDIA PRIVATE LIMITED are genuine, given and signed by the persons
whose names appear on them. I have never been involved in any criminal activity and do not pose security risk to any vessel assigned.
Any false declaration may render me liable for termination or dismissal.

Date: Signature of applicant: ___________________________

12. SPACE FOR OFFICIAL USE

Assessment Grade
Personality
Attitude
Technical Knowledge
English Knowledge

Over Assessment

GRADE : A-Excellent , B-Good , C- Satisfactory , D-Average , E-Poor

Application status: Date :

Forwarded to D’Amico Rome

D’AMICO ROME’S ACCEPTANCE DETAILS
ACCEPTED YES NO
REF.
Interviewed by Date:

INTERVIEWER’S REMARKS :