1. APPLICATION FORM
RANK APPLIED FOR
CHIEF OFFICER/SKIPPER Date of Availability
As soon as posible
NAME OF
APPLICANT
Hajdukovic Milan
Citizenship Montenegrin Age: 50
E-mail : milanhaj@gmail.com
Home
Address
BB. Bjelisi, 85000 Bar- Montenegro
Telephone No.
GSM No.
00382 69 552405 Mob.
Date and place of Birth Bar , 19.01.1965
Marital Status Mareed No. of Children : 2 ( two ) dother
NEXT OF KIN Hajdukovic Kristina Relationship : Dother
Address Same as above Tel : 00 382 69 467450 Bjelisi, b.b.
PERSONAL DOCUMENTS Number Place Issued Date Issued Valid Till
Seaman’s Discharge Book 1834 Bar 27.10.2014 27.10.2024
Passport B83LZ7017 Bar 28.05.2013 28.05.2026
USA visa ( if any )
Other Visas
NAT. LICENCE Capacity Number Place/Date
Is.
Valid till
Certificate / Endorsment Master from 500 to 3000 grt No. 0404-403-
2831/13 Montenegro
14.11.2013
31.12.2016
Certificate / Endorsment Officer in charge on ships off
500 or more
No 02-1011 Bar
11.03.2011
11.03.2016
FLAG ENDORSEMENTS Number Place Issued Date Issued Class / Grade
Montenegro Same as above Bar- Montenegro 14/11/2013 Master Licence up to 3000
GRT
Montenegro Officer in charge of
Navigational watch on ships /
500 grt to 3000 grt.
Bar-Montenegro
Bar
11.03.2011
Ch.Mate
St.Vincent and the Grenadines Officer in charge of a
Navigational watch (II/1)
D/G130221162951
/G
Geneva-
21/02/2013
Ch.Mate
CERTIFICATES HELD Number Place Issued Date Issued
Basic safety A-VI/1 04-979 Bar 10.03.2011
PSCRB VI/2 04-980 Bar 10.03.2011
Med. First Aid VI/4 04-981 Bar 10.03.2011
Medical Care VI/4 04-982 Bar 10.03.2011
Adv. F.F. VI/3 04-983 Bar 10.03.2011
GOC IV/4 Radar-04-5223/2 Kotor 23.10.2015
ROC R.874/2015 RAA Kotor 23.10.2015
Dang. Cargo B-V/4,V/5 04-5014 Bar 30.11.2010
Tank er Basic V/1-1 04 - 984 Bar 10.03.2011
Platform Supplay Vessel PCV 10/149 MA/D00283 Marrseille-France 21.10.2010
Dynamic Position
Simulator Course
No. DP 0478 Split -Croatia 24.02.2011
Dynamic Position No. DP 0444 Split- Croatia 25.10.2010

2. B/Induction Course
Helicopter Underwater
Eskape Training Course
HUET- 020/2011 Split-Croatia 08.03.2011
DPO LOG BOOK No.0478 Split -Croatia 24.02.2011
SSO No.04-5223/2 Kotor 28.10.2015
SECURITY Awarnes IMETA/COP/5711 Singapure 29.11.2013
LNG FAMILIARISATION Miaheel Staufeldt Soyo- Angola 02.05.2012
Familiarization Train. A-
VI/1
O4 - 978 Bar 10.03.2011
GMDSS 0405-403-8950/15 Kotor 29.10.2015
ECDS No.810/2015 Bar 27.10.2015
Managament &Tim Work
on board
No.803/2015 Bar 26.10.2015
Bridge Resources
Menagment
No.808/2015 Bar 31.10.2015
English Language
Test/Marlin’s Test
No.59EE8A210D74BE8B Kotor 27.10.2015

3. HEALTH CERTIFICATE Intnl. / Flag Date Issued Validity Drug & Alcohol Test
Bar - Montenegro Montenegro-Kotor 27.10.2015 27.10.2017 Montenegro-Kotor
International Medical Report Montenegro-Bar 06.09.2014 06.09.2016 Montenegro-Bar
ADDITIONAL EDUCATION COURSE OF GERMAN SHIPPING LAW- MSG MARINE SERVE-HAMBURG,/12.05.2010
ADDITIONAL TRAINING PAUSE- TRAINING COURSE(WEST AFRICA) ON 28th April 2007
LANGUAGE V. Good Good Satisfactory Poor
English Yes
Spanish Yes
SEA SERVICE FOR LAST 7 YEARS OR MORE SHIPS
Vessel’s Name Period at sea
months days
Signed on Signed off Position Type of
Vesl.
BRT Type of
ME
Seabulk Raven 02/07 02.03.2007 06.05.2007 2nd mate AHTS 1608 Man 7760
SB Raven 02/01 04.07.2007 03.09.2007 2nd Mate AHTS 1608 Man 7760
SB Raven 03/10 07.11.2007 15.02.2008 2nd/Ch.M AHTS 1608 Man 7760
SB Raven 02/00 23.04.2008 23.06.2008 2nd Mate AHTS 1608 Man 7760
SB Raven 02/00 27.08.2008 27.10.2008 2nd Mate AHTS 1608 Man 7760
Seacor Express 02/10 17.12.2008 26.02.2009 2nd Mate AHTS 1777 Man 5280
Seacor Express 03/09 21.08.2009 30.11.2009 Ch.Mate AHTS 1777 Man 5280
Bourbon Artabaze
00/24 15.07.2010 09.08.2010 Ch.Mate AHTS 2343 Motor 2x4000k
Bourbon Liberty 115 02/00 16.08.2010 18.10.2010 Ch.Mate PSV 1517 D.Elect. 2582
Bourbon Liberty 115 01/26 05.12.2010 29.01.2011 Ch.Mate PSV 1517 D.Elect. 2582
Bourbon Liberty 115 02/04 25.03.2011 29.05.2011 Ch.Mate PSV 1517 D.Elect. 2582
Warlock 02/02 13.09.2011 13.11.2011 Ch.Mate AHT 609 Man 5300
Svitzer Soyo 02/15 11.04.2012 26.06.2012 Ch.Mate TUG/ ASD 601 Nigata 2x2200
Svitzer Soyo 03/15 07.09.2012 18.12.2012 Ch.Mate TUG/ ASD 601 Nigata 2x2200
Svitzert Soyo 03/03 09.02.2013 10.05.2013 Ch.Mate TUG/ ASD 601 Nigata 2x2200
Svitzer Soyo 01/21 25.07.2013 14.09.2013 Ch.Mate TUG/ ASD 601 Nigata 2x2200
Svitzer Soyo 02/04 19.12.2013 19.02.2014 Ch.Mate TUG/ ASD 601 Nigata 2x2200
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY ABILITY AND THAT NO CERTIFICATE OF COMPETENCE OR LICENCE ISSUED TO ME HAS
EVER BEEN REVOKED OR SUSPENDED.
I UNDERSTAND THAT PREVIOUS EMPLOYERS MAY BE ASKED FOR INFORMATION CONCERNING MY EMPLOYMENT RECORD WITH THEM AND I HEREBY RELEASE FROM LIABILITY
OR DAMAGE THOSE INDIVIDUALS OR COMPANIES WHO PROVIDE SUCH INFORMATION.
Place and date : Bar , 07.11.2015
Signed : Hajdukovic Milan