This document is an application form for various maritime positions completed by Krzysztof Pietryczuk. It includes his personal details, contact information, documents like passport and medical certificates, qualifications and certificates of competence in areas like navigation watch and dynamic positioning, courses completed, education history from maritime academies, language skills, and previous sea service experience on vessels of different types and flags working in roles like deck cadet, nautical officer assistant, and fire guard. The applicant agrees to the use of his personal data for the recruitment process including potential transfer to employers abroad according to Polish law.

1. Application Form
Rank: OOW, DP Trainee, AB Ready From: 27.11.2014
Family Name Given Name Date of Birth Place of Birth
Pietryczuk Krzysztof 05.10.1987 Hajnowka
Nationality Citizenship Marital Status Children under age of 18
Polish Poland Single
Home Address E-mail Telephone No. / Mobile No.
Legionów 46/14 street
k.pietryczuk@gmail.com +48 694083194
81-404 Gdynia
Next of Kin (state address only if different from above) Relationship
Ul. Sadowa 20, 17-200 Hajnówka
Mother
PERSONAL DOCUMENTS Number Point of issue Date of issue Date of expiry
Passport ED1900142 Wojewoda
Pomorski/2/
01.06.2012 01.06.2022
Seaman’s Book 0241387 MARITIME OFFICE
GDYNIA
05.08.2008 valid
indefinitely
Visas C1/D USA WARSAW 25.02.2013 21.02.2022
HEALTH CERTIFICATE Date of examination Date of expiry Drug & Alcohol Test
Health Certificate 17.01.2014 17.01.2016 negative
Yellow Fever Vacc. 06.01.2010 06.01.2020 -
CERTIFICATES OF COMPETENCE
Main Certificate of Competence Number Date of issue Date of expiry
OFFICER IN CHARGE OF A
NAVIGATION WATCH
GUM-13143-104687-4326/2013
26.09.2013
31.12.2016
(OOW Licence)
RATING FORMING PART OF
A NAVIGATIONAL WATCH
CERTIFICATE
GUM-54141-104687-3700/2009
09.09.2009
valid indefinitely
DP Qualification
X DP Basic/Induction  DP Advanced/Simulator  DP Operator  DPO Limited  DP Maintenance
STCW and OFFSHORE Courses
Name of Certificate Number Date of issue Valid until
Personal Survival Techniques GUM-5412-104687-3400/2013 21.02.2013 20.02.2018
Basic / Advanced Fire Fighting GUM-5415-104687-17730/2009 08.10.2009 31.12.2016
First Aid / Medical care GUM-5421-104687-18889/2009 29.10.2009 31.12.2016
Personal Safety & Social Resp. GUM-5408-104687-3434/2013 21.02.2013 20.02.2018
Survival Craft & Rescue Boat GUM-5419-104687-1662/12 26.03.2012 valid indefinitely
ECDIS In progress .2014 valid indefinitely
GMDSS GG-22916 11.09.2013 11.09.2018
ARPA & Radar GUM-5425-104687-20340/2009 26.11.2009 valid indefinitely
Tanker Familiarization GUM-5437-104687-3355/2013 20.02.2013 19.02.2018
Proficiency in Security-awarness GUM-1350-104687-18540/2013 01.10.2013 valid indefinitely
Proficiency for seafarers with
GUM-1351-104687-18580/2013 01.10.2013 valid indefinitely
designated security duties
GWO working at heights 36134/150/14 22.07.2014 22.07.2018
HUET 36561/2931/41 17.09.2014 17.09.2018
BOSIET 36996/1224/14 18.09.2014 18.09.2018
HDA (Helideck Assistant) 36997/1224/14 10.11.2014 10.11.2017
Hereby agree to the use of personal data included in my job application as required by the recruitment process including t ransfer to potential
employers abroad (in accordance with Polish law of 29th September 1997 regarding protection of personal data Dz.U. Nr 133 poz. 833)

2. EDUCATION
Elementary / Secondary / University Name of the school/profile and year of completion
University/Academy
Maritime Academy in Gdynia “Offshore Technology” /2014
Polish Naval Academy in Gdynia “Navigation” /2011
FOREIGN LANGUAGES Good/Very Good Satisfactory Beginner
English X
Russian X
Norwegian X
Passed English Marlins test (89%) and CES 5.1 test (83%)
PREVIOUS PROVABLE SEA SERVICE PERIODS
Company Vessel’s name Rank Type Flag GT / HP From date To date
Stan Shipping BLACKFORD DOLPHIN Fire
Guard/Helper/Tran
slator
Semi Sub Drilling Rig SINGAPURE 19442 24.02.2014 06.06.2014
Davydovsky TANAIS 2nd Officer Gen. Cargo POLAND 299 12.08.2013 09.11.2013
Hartmann JS JAGUAR Nautical Officer
Assistant
LPG TANKER SINGAPURE 5036 08.03.2013 05.08.2013
Stena Line STENA SPIRIT Deck Trainee RO-RO /PASSENGER BAHAMAS 39193 05.10.2012 15.02.2013
“WUŻ” Port and Maritime
AGIS OS TUG POLAND 344 01.06.2012 01.09.2012
Services GDAŃSK
Chipolbrok LEOPOLD STAFF Deck Cadet GENERAL CARGO CYPRUS 24 167 19.04.2010 25.08.2010
WUŻ PUŻ Gdynia HEROS OS/cadet TUG POLAND 365 29.07.2009 29.08.2009
WUŻ PUŻ Gdynia HEROS OS/cadet TUG POLAND 365 06.08.2008 16.10.2008
Gdynia, on the day of 26.11.2014
Signature Krzysztof Pietryczuk
Hereby agree to the use of personal data included in my job application as required by the recruitment process including transfer to potential employers abroad (in accordance with Polish law of 29th September
1997 regarding protection of personal data Dz.U. Nr 133 poz. 833)