1. 1. Personal Data
First Name
IGOR
Middle Name (s)
Vyacheslavovich
Last Name / Surname
SISYOV
Nationality / Citizenship
UKRAINIAN
Country of Origin
UKRAINE
Date of Birth:
05.04.1989
(DD.MM.YYYY)
Place / City of Birth
ODESSA, UKRAINE
Marital Status1
: MARRIED Gender : Male
Female
Religion: CHRISTIAN
1
Select from: ●Single ●Married ●Divorced
Rank applied for: 2ND
OFFICER Willing to accept lower rank? Yes
No
Available From (date): Mid-Sep-16
(DD.MM.YYYY)
Primary / Permanent Address:
25, PAUSTOVSKOGO STR.
Alternative / Temporary Address:
(DD.MM.YYYY)
N/A
City: ODESSA Post Code: City: Post Code:
State: Country : UKRAINE State: Country:
Nearest Airport : ODESSA Home Tel.: Phone:
Mobile Tel.: +380 938 749371 Fax: Email: sisyova@mail.ru
Contact Method : Email Fax Mobile Phone Home Phone Post
Eyes: green Hair: brown Height: 185cm Weight: 85kg
Specify size as S, M, L, XL, XXL for: Boiler suit: XL Safety shoes: 44
2. Personal ID / Documents / Visa
Type of Document / ID 1
Number
Date of Issue
(DD.MM.YYYY)
Date of Expiry
(DD.MM.YYYY)
Country of
Issue
Issuing
Authority /Body
Seaman’s Book (National) 00650/2015/24 17.02.2015 UKRAINE Port Odessa
Seaman’s Passport (National) AB 547963 04.03.2015 04.03.2020 UKRAINE Port Odessa
Seafarer’s ID (RUS)
Passport FB930462 17.11.2015 17.11.2025 UKRAINE 5101
US Visa C1/D L0531289 25.01.2016 21.01.2026 UKRAINE US Emb., Kyiv
Seaman’s Book (LBR) 1083842 11.01.2013 11.01.2018 Virginia, USA LBR Mar. Auth.
Social Security/Personal ID No. Marlins
Seagull (CES 4.1)
3. Nominee / Next of Kin & Family Details
Full Name of Nominee for compensation in case of fatality:
SISYOVA OLEKSANDRA
Relationship1
WIFE
Gender : Male
Female
Nationality: UKRAINIAN
Address: THE SAME
City: ODESSA Post Code: Country: UKRAINE
Email: sisyova@mail.ru Tel: Mobile: +380 93 188 24 43
1
Select From: ●Spouse ●Partner ●Child ●Parent ●Grand Parent ●Other Relative (Please Specify)
Family Data:
Relationship First Name Last Name Date of Birth Passport No. Issued Valid until Country of Issue
1
Select as applicable: ●Passport ●Seamans Book ●Seaman Passport ●Seafarers’ Identity Document ●Registration Book ●National ID Card ●PAG-IBIG
Housing Insurance ●Health Insurance ●Overseas Emp Cert ●PHL Card ●Pension Fund ●Provident Trust ●Professional Organisation ●Driving Licence ●Visa
2. Spouse / Partner2
Child M F Vladislava Sisyova 24.12.2015
Child M F
Child M F
Child M F
Indicate type of valid visa3
USA Canada Brazil Schengen UK Other
2
Strike out inapplicable item3
Please consider period on board
4. STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications:
(Add separate sheet if data exceeds space available.)
Description of Certificate of Competency Number
Date of Issue
(DD.MM.YYYY)
Date of Expiry
(DD.MM.YYYY)
Country of Issue
(A) Reg II / 1-4, III / 1-4 Officers Certificate of Competency & Ratings Watch-keeping Certificate (including flag state endorsements)
Chief mate on Ships of 500GT and more 10930/2015/07 06.03.2015 05.03.2020 UKRAINE
Chief mate on Ships of 500GT and more 11710/15 04.06.2015 05.03.2020 GIBRALTAR
4 Enter here actual description given in the Competency Certificate / Watch keeping Certificate held by you
(B) Reg V / 1 – Special Requirement for Tankers
Description
Level1: Mngmnt
Level2: Operational
Level3: Support
Number
Date of Issue
(DD.MM.YYYY)
Date of Expiry
(DD.MM.YYYY)
Country of Issue
Endorsement – Oil Mngmnt 10533/2015/07 06.03.2015 05.03.2020 UKRAINE
Endorsement – Chemical Mngmnt 10534/2015/07 06.03.2015 05.03.2020 UKRAINE
Endorsement – Gas
(C) GMDSS Certificates (including flag state endorsements)
GMDSS COC (National) GOC 10929/2015/07 06.03.2015 05.03.2020 UKRAINE
GMDSS Endors (National) GOC 10929/2015/07 06.03.2015 05.03.2020 UKRAINE
GMDSS Endors (MHL)
GMDSS Endors (LBR)
GMDSS Endors (GIB) GOC 11710/15 04.06.2015 05.03.2020 GIBRALTAR
GMDSS Endors (........)
(D) Reg I
Personal Training Record Reg I/14
Medical Fitness Certificate Reg I/9
Yellow Fever N/A 12.05.2008 12.05.2018 UKRAINE
Chem Blood/Liver Test Certificate
Drug & Alcohol Test
Flag State Medical Cert (MHL)
Flag State Medical Cert (LBR)
Flag State Medical Cert (........)
Flag State Medical Cert (........)
(E) Certificates / Courses
3. Description of Cert / Course
STCW 95 Ref /
IMO Model
Number
Date of Issue
(DD.MM.YYYY)
Date of Expiry
(DD.MM.YYYY)
Country of
Issue
Radar Simulator / ARPA A-II/2 03686 10.02.2015 10.02.2020 UKRAINE
Bridge Team and Resource Management A-VIII/2, B-VIII/2 0134/2012 18.11.2015 18.11.2020 UKRAINE
Engine Room Simulator
A-III/1,A-VIII/2
B-VIII/2
Engine Room Resource Management
A-III/1,2,3, A-VIII/2,
B-VIII/2 / IMO 2.07
Ship’s Handling Simulator A-II/2, B-V/a
Electronic Charts System (ECS) A-II/1
Electronic Charts Display & Info System (ECDIS) A-II/1, A-II/2 07851 10.02.2015 10.02.2020 UKRAINE
Usage of Automatic Identification System (AIS)
A-II/1, A-II/2 /
IMO Res.A.917(22)
Tanker Familiarisation (Oil) A-V/1.1. p. 2-7 04611 10.02.2015 10.02.2020 UKRAINE
Tanker Familiarisation (Chemical) A-V/1.1. p. 2-7 04611 10.02.2015 10.02.2020 UKRAINE
Tanker Familiarisation (Gas) A-V/1.1. p. 2-7
Tanker Specialized (Oil) A-V/1.2, p.8-14 01661 10.02.2015 10.02.2020 UKRAINE
Tanker Specialized (Chemical) A-V/1.2, p.15-21 01030 10.02.2015 10.02.2020 UKRAINE
Tanker Specialized (Gas) A-V/1.2, p.22-34
Basic Safety Training1 A-VI/1 00623 10.02.2015 10.02.2020 UKRAINE
Personal Survival Techniques A-VI/1-1
Fire Prevention and Fire Fighting A-VI/1-2
Elementary First Aid A-VI/1-3
Personal Safety & Social Responsibility A-VI/1-4
Proficiency in Surv Craft and Rescue Boat A-VI/2-1 00925 10.02.2015 10.02.2020 UKRAINE
Fast Rescue Boat N/A
Advanced Fire Fighting A-VI/3 00615 10.02.2015 10.02.2020 UKRAINE
Medical First Aid A-VI/4-1
Medical Care A-VI/4-2 0634/2012 07.12.2012 07.12.2017 UKRAINE
Ship Security Officer A-VI/5 & B-VI/5 15555 10.02.2015 10.02.2020 UKRAINE
Ship Safety Officer N/A
Marine Pollution & Prevention OPA-90 N/A
Energy Conservation CDI 2000
Risk Assessment TMSA
Incident Investigation TMSA
Liquid Cargo & Ballast Operations simulator A-V/1, A-I/12 / 2.06
Ice navigation N/A 2/032/12 25.10.2012 25.10.2017 UKRAINE
Preparation for Port State Control & Vetting
Inspections for Officers
MARPOL 73/78,
SOLAS-74/86
ISM Code ISM Code Part A 6
Vapour Emission Control (VEC) CFR 46: 39.10-11
Chemical Tanker Training
ISM 6.3 & TMSA
element 3b part 2
FRAMO pumps N/A
TRANSAS SPECIFIC TRAINNG N/A 0265/2013 12.07.2013 12.07.2018 UKRAINE
Navigation and watch keeping N/A
Vessel General Permit for discharges incidental to
the normal operation of vessels (VGP) (CBT)
33 USC 1251 et
seq.
ISPS Crew / Ship Security Awareness
ISPS Code Part B-
13.3 & 13.4
English Language N/A
Operational Safety Awareness On Board Tankers TMSA Element 3B
Bridge Communication Res. 8, Sec. B-VIII/2
1
4. 5. Sea Experience: (Start the listing below with the most previous experience)
Company Vessel Name Built Flag (1)
Type (2)
DWT GRT Main Engine (2)
BHP / KWT Rank
Date From
DD.MM.YYYY
Date To
DD.MM.YYYY
Odessa Port KENTAVR 2001 UKR TUG 165 800 BHP Deck Cadet 01.06.2007 31.08.2007
Odessa Port KENTAVR 2001 UKR TUG 165 800 BHP Deck Cadet 01.06.2008 30.07.2008
CMA CGM CMA CGM HERODOTE 2007 UK GCD 20786 17594 B&W AA 2322 33250 / 24450 Deck Cadet 24.03.2009 31.07.2009
Omega Management Inc. OMEGA LADY SARAH 2004 MHL TNС 70500 41787 MAN B&W 6S 60MC 16680 / 12268 Deck Cadet 17.03.2011 31.07.2011
Omega Management Inc. OMEGA LADY SARAH 2004 MHL TNС 70500 41787 MAN B&W 6S 60MC 16680 / 12268 3rd
Officer 01.08.2011 22.09.2011
Omega Management Inc. MEGACORE PHILOMENA 2010 MHL TNP 74574 42208 MAN-B&W 6S 60MC-C 18436 / 13560 3rd
Officer 01.04.2012 22.07.2012
Ernst Jacob NELL JACOB 2003 LBR TNС 160292 81236 MAN B&W 6S 70MC 21940 / 16133 3rd
Officer 28.12.2012 10.06.2013
Ernst Jacob JILL JACOB 2003 LBR TNС 72908 40037 MAN B&W 6S 60MC 16646 / 12240 3rd
Officer 24.10.2013 16.04.2014
Ernst Jacob JOHANN JACOB 2000 LBR TNС 73071 40037 MAN B&W 6S 60MC 16646 / 12240 3rd
Officer 29.09.2014 21.01.2015
Ernst Jacob JACQUES JACOB 2000 GIB TNP 71345 40705 Sulzer 6RTA62U 16320 / 12000 2rd
Officer 08.06.2015 29.09.2015
Ernst Jacob JACQUES JACOB 2000 GIB TNP 71345 40705 Sulzer 6RTA62U 16320 / 12000 2rd
Officer 16.02.2016 19.06.2016
(1)
Use only the following abbreviations for vsl flag:
ANT Netherlands CAY Cayman Islands GEO Georgia LBR Liberia MLT Malta RUS Russia UK United Kingdom
ATG Antigua & Barbuda CYP Cyprus GIB Gibraltar LTU Lithuania NGR Nigeria SAU Saudi Arabia UKR Ukraine
BER Bermuda DIS Denmark, 2nd
reg. IOM Isle of Man LVA Latvia NIS Norway, 2nd
reg. SGP Singapore
BHS Bahamas EST Estonia ITA Italy MHL Marshall Islands PAN Panama SWE Sweden
(2)
Use only the following abbreviations for vsl types:
B/C Bulk Carrier FSH Fishing Vsl LOG Log/Timber O/O Ore/Oil Carrier SUL Self-Unloader
CON Cellular Container FSO FloatingStorageOffldg LPG LPG Carrier OTH Other TUG Tug
CH1 Chem Tanker IMO I FPS FloatgProdStorOffldg MLP Multi-purpose PAS Passenger Ship YAT Yacht
CH2 Chem Tanker IMO II GCD General Cargo MSV MultiServiceVessel RFG Reefer Vessel TNB Tanker (Bitumen)
CH3 Chem Tanker IMO III HLV Heavy Lift Vsl NVL Naval Ship R/R Ro/Ro Carrier TNC Tanker (Crude)
DRG Dredgers LSH Lash RIG OffShore Oil Rig PRR RoRo-Pax TNP Tanker (Products)
DP Dynamic Positioning LIV Live Stock Carrier OSV OffShore Supply Vsl SAL Sailing Vsl TNS Tanker (Storage)
ETH Ethylene Chem Tanker LNG LNG Carrier OBO Ore/Bulk/Oil Carrier SRV Survey Vessel TNV Tanker (VLCC/ULCC)
(2)
Engineers to give make/model of engines, e.g. “MAN 14V52/55A” or “SULZER 5RTA58”
