CMA SHIPS Singapore OPERATIONS MANUAL SECTION 3

Ref: Crew/Form/01a Version: 01/07/2015 PAGE 1 of 1

TITLE: APPLICATION FORM

APPLICATION FORM ATTACH

RECENT
PHOTO

ADD NAME AND ADDRESS OF RECRUITING AGENCY

Position applied for: 3rd Engineer

Type of vessel: Conteiner Bulk carrie General cargo/Heavy-lift
Availabibity date: 8/1/2023

Are you responding to a media advertisement? YES/NO

If YES, please state which one

Are you applying upon personal or professional recommendation? YES/NO

If YES, please state who

Surname: Shpak First name: Stanislav

Other names Known as Nationality: Ukranian

Place of birth: Odessa Date of Birth: 7/2/1998 Age:25 Male Female

Passport
Date
Number Place of issue of Date of expiry Issuing Authority
issue
FF620068 Odessa ### 3/2/2027 5116

Visas
Type Number Place of issue Date of issue Date of expiry
C1/D (USA)
C1 (USA)
D (USA)
Australia Entry visa 2.009503E+12 2/2/2021 2/2/2024
MCV (Australia)
Schengen

Education Background
School / College From To Highest qualification attained
MCTF NU OMA 2014 2018 Third-class engineer

Personal details
Full address: Zabolotnogo
56/2 ap.81
Postal code: 65001 Country: Ukraine

E-mail: stasshpak1@icloud.com

Home tel number: N/A

Mobile phone: +38(063) 456 60 27 WhatsUp,Viber,Telegram applicate

Chisinau
Domestic Airport International International Airport
Airport
Marital status:

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Full name of Next of Kin: Shpak Aleksey Relationship Uncle
Address of Next of Kin
Zabolotnogo 56/2 ap.81
if different from above
Phone +38(093) 837
if different from above 43 65

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Dependents
Name Date of birth Age Gender Relationship

Person to contact in case of emergency

Name: Hun Karina Relationship Wife
Zabolotnogo
Address:
56/2 ap.81
Phone number: Mobile number:+38(093)837 43 65

National Seaman's Book

Date
Number Place of issue of Date of expiry Issuing Authority
issue
AB589410 Odessa ### 12/10/2025 Port Odessa

National Certificate of Competency (COC)- Licences

Date
Issuing
Grade Number of Date of expiry Place of Issue Date revalidated Date expiry
Authority
Third-class engineer issue
Port Odessa 01758/2018/08 ### 7/27/2023 Odessa
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National GMDSS & Endorsement

Date
Issuing Authority Number of Date of expiry Place of Issue
issue

Medical Fitness Certificate

Type Date of issue Date of Expiry

Yellow Fever Vaccination

Date of Issue Date of Expiry
4/17/2017

Foreign languages other than English

Level: Begin
Language ner Intermediate Advanced
English X

Medical History
Have you ever signed off from
Yes / No If yes give details
a ship due to medical reasons?
Name of vessel Date of Occurrence

Brief description of Illness or Injury

Other personal details

Height:185 sm Weight: 85 Colour of Hair: black

Colour of eyes: brown Safety shoes size: 43 Boiler suit size: XL

Uniform Shirt size: L Uniform Trousers XL

size:

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Details of other Marine courses
IMO model
Type of Marine Course Reference- Regulation Number Date of issue Date of expiry
course
1.19 - 1.20 1.13 - STCW Reg.
Basic Training 1.21 A-VI/1-1 to A- 25/2021/84 1/27/2021 1/27/2026
VI/1-4
Personal Survival STCW Reg. A-VI/1-1
1.19
Techniques

BASIC TRAINING
STCW Reg A-VI/1-2
Basic Fire Fighting 1.20

STCW Reg A-VI/1-3

Elementary First Aid 1.13

Personal Safety & Social STCW Reg A-VI/1-4

Responsibilities (Human 1.21
Relationship)

Proficiency in survival craft & Rescue STCW Reg A-VI/2 par

Boats
1.23 1410124 12/14/2021 12/14/2026
1.3
STCW Reg A-VI/3
Advanced Fire Fighting 2.03 5774 4/26/2018 4/26/2023

STCW Reg A-VI/4-1

Medical First Aid 1.14 4529 4/26/2018 4/26/2023

STCW Reg A-VI/4-2

Medical Care 1.15
par 2
STCW Reg II/2
ROP 1.08

STCW Reg II/1

ARPA / NCC 1.07

Radar Simulator

STCW Reg II/1

ECDIS 1.27
par.2.5
US 49 CFR 172.700-
HAZ MAT
172.204
STCW
Ship simulator bridge teamwork 1.22
Reg
II/1
BTM / ETM

STCW Reg VI/5 /

Ship Security Officer (SSO)
ISPS Code

BASSnet

STCW Reg II/1 & II/2

Ship handling & manoeuvring

STCW Reg VIII/2

Bridge resource management
US33CFR 157.415

Loading software (name it)

Large Vessel Handling Simulator / CMA CGM

Engine Room Simulator

Indos Number

Upgradation Course

Revalidation Course for renewal of CoC

High Voltage Training

Reefer Training

Engine Maker’s Training

Crane Manufactures training

ISPS
Vessel security training course
code
IMO Assembly Res
Ship Safety Officer
A741(18)
UK MCA
ISF Marlins English test

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Flag State Documents
Document Grade Number Place of Issue Date of Issue Date Expiry

Malta:

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Employment history (at least the last 5 years)

Vessel * Company Manning Agent Trading area Vesse Flag DWT / Year Main Engine Position Sign on Sign off Total Reaso
l type TEU built date date mm/dd n for
** Make Type KW
leaving
***
Aqua Diamond UMA UMA Asia BC liberia 49000 2004 MAN B&W 2 stroke 7150 Oiler
13/05/19 10/09/19 4/0 EOC

Atlantic Harmony Marlow Navigation Istambul Shiping world wide 2017

MAN B&W 6S40ME-B
2 STROKE 6480 Oiler 8/22
GC Hong Kong 22,362 23/01/20 01/10/20 EOC

Caribbean Harmony Marlow Navigation Istambul Shiping world wide 2017

MAN B&W 6S40ME-B
2 STROKE 6480 3rd Engineer 8/22
GC Hong Kong 22,362 05/02/21 28/10/21 EOC

Sevgi Marlow Navigation Istambul Shiping world wide 2014

MAN B&W 6S40ME-B
3 STROKE 6480 3rd Engineer 06/05
GC Hong Kong 20,362 28/10/22 03/05/23 EOC

* or industry sector if ashore

** Use abbreviation: PC = Pure container, GC = General Cargo, BC = Bulk Carrier, LNG = Tanker, LPG = Tanker, Chem = Chemical, RoRo = Roll on Roll off
*** Use abbreviation: MR = Medical Reason, VS = Vessel Sold, EOC = End of Contract
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Summary of Experiences (in number of years)
Years Bulk
Container Tanker Roro others (Please state)
as/ on carrier
Master -
C/E
C/O - 2/E

2/O - 3/E 1 year 2 mounth

3/O - 4/E

E/O

Total

Years Sulzer Sulzer SEMT Steam

B&W MAN others
as/ on RTA RND Pielstick Turbine
C/E

2/E
1 year 2 1 year 2
3/E
mounth mounth
4/E

E/O

Total

References
Do you have any objection if we will contact your last employers for
Yes/No No
reference?
If YES please specify why:
If NO please specify below:
Please give the name and address of your current or immediate past
employer
Name of company Marlow Navigation Ukraine
Name of person to
Svetlana
contact
Address Troitskaya str., Odessa, Ukraine

Tel number +38(068)7169956

Please list two contactable referees or past employers

Name of company
Name of person to
contact
Address

Tel number

Name of company
Name of person to
contact
Address

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Tel number

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Bank details
Bank
Sort code:
name:
Branch Swift name
name IBAN number:

Address:
Account
Account
name/
number:
Title

I hereby affirm that all the information provided by me in this application is true and correct to
the best of my knowledge and belief; further, that no Certificate of Competency or License
issued to me has ever been revoked or suspended. I also certify that my medical history
contained abocve is true and any false statement or undisclosed material information about
past illness or injury will disqualify me from any employment benefits and claims.

Date_15.05.2023___
_____ Signature_______________________

* The company may contact my previous employer for references.

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