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APPLICATION FORM

1, Sobornaya square, Odessa, Ukraine, 65045 Tel.: +38 095 188 86


76 E-Mail: crew@nykicrew.com
www. nykicrew.com

Position Applied For: Cadet Date of Availability: 04.01.2025 Salary: 500$

1. Personal Particulars
Surname: Petukhov Name: Artem
Date of Birth: 03.01.2007 Place of Birth: Kherson reg., Nationality: Ukrainian
Ukraine
Father’s Name: Oleksey Father’s Surname: Petukhov
Mother’s Name: Oksana Mother’s Surname: Petukhova
Overall: 48 Shoes: 43 Height: 190 Weight: 67 Hair : Brown Eye : Brown
Home address: Ap.18, 21/2, Kosmonavtiv Street, Odessa, Ukraine Nearest Airport: Bucharest
Mobile phone: +380937211509
E-mail: artempehov033@gmail.com Skype:
Marital Status: Male Number of Children:
Next of Kin(Name & Relation): Mather
Home address : Ap.17, 21/2, Kosmonavtiv Street, Odessa, Ukraine
Mobile phone: +380958140377
2. Passports
No Place of Issue Date of Issue Date of Expiry
Seaman’s Book AC015776 Port Odessa 06.09.2024 06.09.2029
Travel Passport GE264802 Odessa 26.20.2022 22.06.2026
3.Certificates of Competency & Endorsements
Date of
No Grade Place of issue
issue/validity
COC/ENDORSEMENT
4. Visas
No Date of Issue Date of Expiry
AMERICAN
5. STCW Certificates
No Place of Issue Date of
Expiry
A-IV/2 (GMDSS/ENDORSEMENT)
A-VI/1 (Basic Safety Training) 18852 24.07.2024 24.07.2029
A-VI/2 (Proficiency in Survival Craft and Rescue Boats other
15879 24.07.2024 24.07.2029
than Fast Rescue Boats)
A-VI/2 (Proficiency in Fast Rescue Boats)
A-VI/4 (Medical First Aid/ Medical Care) 11555 18.10.2024 18.10.2029
A-VI/3 (Advanced Fire Fighting) 14491 18.10.2024 18.10.2029
A-II/1 (ARPA)
A-II/1 (Radar Observation & Plotting)
A-II/2 (Ship Handling Arrangements)
A-III/2(Maintenance of Electrical & Electronic Engineering )
A-I/12 (Operational Use of Electronic Chart Display and
Information System) IMO Model 1.27
B-V/4&B/5 (Dangerous and Hazardous Substances)
B-I/12 (BTM/ BRM)
B-I/12 (Engine-Room Resource Management)
A-VI/6 (Security Awareness Training for all Seafarers)
A-VI/6 (Training for Seafarers with Designated Security Duties)
A-VI/6 (Ship Security Officer)
Ship Safety Officer(ISM Code)
A-V/1-1 (Basic Training for Oil and Chemical Tanker Cargo
Operations )
A-V/1-2 (Basic Training for Liquefied Gas Tanker Cargo
Operations)
A-V/1-1 (Advanced Training for Oil Tanker Cargo
Operations)
A-V/1-1( Advanced Training for Chemical Tanker Cargo
Operations)
A-V/1-2(Advanced Training for Liquefied Gas Tanker Cargo
Operations)
6. Sea Service (at least last 5 years)
Crewing Ship Owner Vessel’s name/ Type / DWT
Rank From To
Agency (Name/Country) Flag M.E, / KW
ENG CADET Ukraine Maritime ILYICHEVSK SEA FUSHING STANISLAV TUG/304/CAT 3516-HD,/ 11.09.2024 14.10.2024
group LLC PORT UKRAINE SIREBKO/UKRAINE 4000
Ukraine Maritime ILYICHEVSK SEA FUSHING STANISLAV TUG/304/CAT 3516-HD,/
ENG CADET 05.02.2024 08.07.2024
group LLC PORT UKRAINE SIREBKO/UKRAINE 4000
Ukraine Maritime CONT/3200/SKL
ENG CADET UKRRICHFLOT JSC DNIPRO LINE UKRAINE 24.06.2023 30.12.2023
group LLC 6VD/29/24 AL-2

7. Nautical Education
Name of Marine School(Academy) Department Graduated in (year):
Kherson State Maritime Academy Marine Engineer

8. Medical Examination
Issue Expiry Place of Issue
Physical Examination Report Will pass
Drug & Alcohol Test
Yellow Fever 08.11.2024 08.11.34
English Level: Good Years of Sea Experience (total):
(in the applied rank ):

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