HISTRIA SHIPMANAGEMENT SRL

CONSTANTA
PER
103

APPLICATION FORM / INTERVIEW ( SEA STAFF )
FAMILY NAME :DENISOV MIDDLE NAME: HEIGHT: 70 WEIGHT:1.80
FIRST NAME: MARCEL PIN:
POSITION APPLIED FOR :/DECK OFFICER //HELMSMAN NATIONALITY :ROMANIAN
PERSONAL DETAILS
MARRIED : RELIGION ORTODO
AFI
RECENT
P
HOTO
DATE OF !IRTH : 11.03.1"7" PLACE OF !IRTH :T#LCEA
FOREIGN LANG#AGES :ENGLISH$SPANISH$ITALIAN
PRESENT ADDRESS : T#LCEA/AL#NIS#L#I %%
PHONE :07&'(%(881
NET OF KIN NAME AND ADDRESS :DENISOV MARIANA
PHONE :07(780%"'7
FAMILY DETAILS
WIFE AND CHILDREN NAMES DATE OF !IRTH CHILDREN NAMES DATE OF !IRTH
DENISOV MARIANA
DENISOV RO!ERT
EDUCATION (COLLEGES / INSTITUTES, ETC)
NAME OF INSTIT#TION CO#RSE ATTENDED DATES )#ALIFICATIONS GAINED
FROM TO
#MC NAVIGATION %008 %01% INGINEER
DETAILS OF DOCUMENTS / LICENCES / CERTIFICATES ( NATIONAL FIRST )
CERTIFICATE N#M!ER GRADE DATE ISS#ED !Y
*+,-, .//012.30,
ISS#ED EPIRES
PASSPORT 11'10(07 0(.0&.0' 0(.0&.1' POLITIA T#LCEA
SEAMAN4S !OOK 1%03"CT %'.08.03 1%.0'.1( ANR CONSTANTA
MEDICAL 13110 30.0&.11 %".0&.1' GALATI
ROMANIAN LICENCE
ENDORSEMENT 38%73 DECK
OFFICER
0(.0%.13 0(.0(.1' ANR CONSTANTA
LI!ERIA
PANAMA
MALTA
OTHER:
IMO COURSES
NAME OF CO#RSE DATE N#M!ER DATE N#M!ER NAME OF CO#RSE
RO RO PASSENGER 11.0'.08 %3&1 30.0&.11 13110 MEDICAL CARE
PROFICIENCY IN FAST
RESC#E !OATS A VI/%
17.0".0" '1% 17.0".0" '1% PROFICIENCY IN FAST RESC#E
!OATS
TANK FAMILIARI5ATION 10.10.08 3(78 0%.1%.1% 177 RADAR ARPA
TRANSPORT AND
HANDLING
1".0&.11 13001 31.01.13 3"&(' GENERAL OPERATOR FOR GMDSS
MARITIME ENGLISH 07.0'.1% 8&00 1%.0%.13 %7( GMDSS
PREVENTION OF
POLL#TION OF THE
1%.0'.11 1%3%0 1".0&.11 13001 TRANSPORT AND HANDLING
PROFICIENCY IN S#RVIVAL
CRAFT
0&.0&.11 %((1( 01.11.13 '781 SSD
ADVANCED FIRE FIGHTING 08.07.11 1&(8%
PERSONAL SAFETY AND
SOCIAL RE
03.0'.11 1&81'
PERSONAL S#RVIVAL
TECHNI)#ES
%(.0&.11 1&003
Form PER 103 - March 2005 Page 1 / 2
RECORD OF PREVIOUS SERVICE
COMPANY RANK SHIP PARTIC#LARS PERIOD REFERENCES
NAME TYPE DWT MAIN ENGINE
!ALEARIA THIRD
MATE
A!
A!EL MAT#TES RO RO
PA
%"'70 0%.0&.136%&.0".13 END OF
CONTRACT
!ALEARIA THIRD
MATE
A!EL MAT#TES RO RO
PA
%"'70 1% 0% .13 607 0( 13 END OF
CONTRACT
!ALEARIA A! A!EL MAT#TES RO RO
PA
%"'70 1&.07.1%61&.10.1% END OF
CONTRACT
!ALEARIA A! 7A#ME I RO RO
PA
3"8" 07.01.1%61'.03.1% END OF
CONTRACT
!ALEARIA A! 7A#ME I RO RO
PA
3"8" 1&.07.11601.1%.11 END OF
CONTRACT
!ALEARIA A! 7A#ME I RO RO
PA
3"8" 1'.0&.116%8.1%.10 END OF
CONTRACT
!ALEARIA A! AVEMARDOS RO RO
PA
&&17 %1.0&.1060&.11.10 END OF
CONTRACT
RODOS A! GI#LIA D
A!#NDO
RO RO
PA
11813 %0.0".0"6%0.0%.10 END OF
CONTRACT
RODOS A! GI#LIA D
A!#NDO
RO RO
PA
1'000 1%.11.086%0.08.0" END OF
CONTRACT
MEDICAL HISTORY (PREVIO#S CHRONICAL / CONTAGIO#S DISEASES)
DATE DESCRIPTION
VERY GOOD
OTHER : HO!!IES$ INTERESTS$ ETC
I .8-,, 9+.9 9+1: C;</.=> <.> ?:, <> /,-:;=.0 @.9. A;- ,</0;><,=9 /?-/;:,:
SEAFARER SIGNED DATE
DENISOV MARCEL DENISOV MARCEL 0'.11.%013
INTERVIEW RESULTS
DATE TEST ASSESSOR COMMENTS
ORAL WRITE
DOC#MENTS (C-,* D,/.-9<,=9)
D.9, R,<.-B: (1A .=>)
CREWING DEPARTMENT
CREWING EEC#TIVE SIGNED DATE
Form PER 103 March 2005
Page 2 / 2