Synergy Maritime Recruitment Services Pvt. Ltd.

,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

Present Rank : 2nd Officer Rank Applied for : 3rd Officer

Surname : Mazur Tel No. 79781843718

Name Sergei Alternate Tel 79066322873

live:mockvavmf
Email ID [email protected] Skype ID White background. 80%
Date Of Birth (DD/MM/YYYY) 5/18/1996 Place of Birth : Ukraine Face

Nationality : Russian Marital Status : Married

Date of Availability : 2/10/2024 Boiler Suit Size : L

Height(cms) 177 Weight(kgs) 78 Blood Group A2+ Shoe Size : 10

62 Antique str. Appt 21 Sevastopol Russia
Address :

Nearest Airport
PAN No for
AADHAR for Indian Indian MUI/NUSI or any other
Nationality Nationality Union Membership No

English Language Proficiency : Speak Average Read Good Write Good

Documents Number Place of Issue Date of Issue Date of Expiry

Passport 0319182026 Russia 12/25/2018 12/21/2035

National CDC 308700 Russia 10/10/2018 Nil

Biometric SID 759925527 Russia 1/29/2018 1/29/2028

U.S. Visa C1/D

Schengen Visa

Grade/
Documents Level Number Issuing Authority Date of Issue Date of Expiry
National Certificate of
Competency (COC) 207248151 Russia 10/3/2022 6/25/2026
CoE - Panama 203788731 Panama 11/10/2022 6/25/2026
CoE - Marshall

CoE - Singapore

CDC - Marshall Islands

CDC - Panama 005402 Panama 11/10/2022 6/25/2026

CDC - Liberia

INDoS No

STCW Certificates Number Name of MTI Date of Issue Date of Expiry

PSSR 1022050590 Russia 1/18/2022 1/18/2027

PSCRB 8012065655 Russia 8/5/2021 8/5/2026

PST

AFF 6012060396 Russia 6/25/2021 6/25/2026

MFA 1022051522 Russia 1/27/2022 1/27/2027

STSDSD 8012065806 Russia 8/7/2021 8/7/2026

High Voltage Training

National Endorsements Number Issuing Authority Date of Issue Date of Expiry

(Where applicable)

GMDSS 207248034 Russia 10/7/2022 10/28/2026

Adv Oil Endorsement 207732077 Russia 7/14/2023 10/12/2027

Basic/Adv Chemical
Endorsement
Basic/Adv Gas
Endorsement
Navigation & Main Date of Expiry
Engine Training Number Name of MTI Date of Issue (Where applicable)
BTM
ECDIS - Generic 7012061750 Russia 7/3/2021 7/3/2026
ECDIS - Type Specific I SID248420K/141460 Panama 10/27/2022 10/27/2023
ECDIS - Type Specific II
ME Engine
RT Flex

Ed 01 Rev No 0
FORM : M 01 Page 1 Of 2
Date:10-Jan-2020
 Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

LICOS 03712 Russia 10/6/2022 10/6/2027

Academic Background
Qualification Name of Institution Board / University Date of Passing Grade /
Percentage
10th Std (SSLC) /Equivalent
12th Std (Hr. Sec) / Equivalent
Pre Sea Training Nakhimov Naval School University 9/1/2017 6/10/2021
Any other Qualification
Family Details - all dependant

No. Name Relation D.O.B Sex Passport No Place of Issue Date of Issue Date of Expiry

1 Kotovskaya Olga Mother

2 Mazur Darina Wife
3
Previous Sea Experience (All Sea Service details from Cadets/Jr level. List recent vessel first)
Deck (Trade & DWT) Period Dates
Type of
Vessel's Name Engine (Type & BHP) Company's Name Rank
Vessel/Flag From To Months/Days
TEU (Containers)

ST.OLGA W/W 28202 Bulk Carrier /Pan Levant Shipping BIB INC 2/O 8/19/2023 12/21/2023 4/2
ST.OLGA W/W 28202 Bulk Carrier /Pan Levant Shipping BIB INC 3/O 10/26/2022 5/4/2023 6/8
Ivory Gull W/W 33000 Bulk Carrier /Liber Roswell navigation corporation OS 10/4/2021 2/28/2022 4/24
Ivory Gull W/W 33000 Bulk Carrier /Liber Roswell navigation corporation OS 7/28/2020 1/28/2021 6/0
Ice Eagle W/W 19740 Crude Oil Tanker/R Roswell Arctic OS 8/16/2019 11/20/2019 3/4
Ice Eagle W/W 19740 Crude Oil Tanker/R Roswell Arctic Deck Cadet 4/19/2019 8/15/2019 3/27

Last Employer name AV Marine PIC & Contact No / Email ID: [email protected] / +7 978 847 53 64
Break in sea service of more than 12 months from last sign off If yes, Candidate to submit self-declaration background security check Form M02 at the
Yes / No
time of Evaluation
Summary of Sea going Experience
For all Officers: Period served on (yy/mm)
BULK CNTR OIL TNKR CHEMICAL

Handymax Panamax Capsize Centre- Feeder Ctnr >8000 Ctnr >14000 Prod. Tanker Aframax VLCC OIL& Chem Parcel

1/9 0/7
For Engineer Officers only : Period served on (yy / mm)

Sulzer B&W MAN Pielstick UEC Doxford Steam UMS CPP Cranes MAK / 4-Stroke

Pump Experience (in months) for All Tanker Seafarers

FRAMO 7 COP

If Yes, in which
Have you been on board vessels during: Drydocking Yes / No Rank No New
Construction Yes / No If Yes, in which
Rank

Have you been involved in any Incidents of Grounding / Fire / Explosion / Collision / Abandon Ship / Rescue / Major oil No
Pollution / Drug Smuggling / Towed or Towing another vessel. If yes, please specify
No
Have you been involved in a court of Enquiry for a Maritime accident ? If yes, please specify
No
Have you ever been involved in a criminal case : If yes on any of the above , give details:
No
Has your present or previous certificate ever been suspended / revoked ? If yes, give details:
No
Do you suffer or have suffered from : Diabetes / High Blood Pressure / Hepatitis / Epilepsy / Nervous Disorders/
Disturbed Vision Or Hearing / Vertigo If yes, give details :
Are you a habitual user of Drugs / Narcotics / Excessive Alcohol. If yes, give details: No
Have you previously worked with multinational workforce? If Yes, What nationalities: No

Declaration by the Applicant:

I understand that a strict medical examination including Drug and Alcohol test as per company requirements is a condition of my employment and I express my willingness to be examined.
I undertake to provide the company’s medical officer full details of my previous medical history. I agree that the decision of the company medical officer is final.
I declare that there are no criminal/ police investigations in progress against me.
I confirm that all my travel documents are valid and in order. I understand that if my travel Documents become invalid or restricted at any time during the course of my employment and cannot be
revalidated by me under normal process, the contract of employment will terminate and all costs of repatriation will be borne by me.
I am /am not presently employed elsewhere.
I am aware that Synergy Maritime Recruitment Services Pvt Ltd., does not have any agents in India for employing Seafarers.
If my application is successful, I will be available to report at your office on or after:_____YES____

If this application sent through candidate's email id, applicant's signature is not required. Candidate should submit the signed application form during the evaluation process/PJF

Name Of Applicant Mazur Sergei Date 1/24/2024 Signature of the Applicant

Ed 01 Rev No 0
FORM : M 01 Page 2 Of 2
Date:10-Jan-2020
 Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

White background. 80%

Face

Sochi

Ed 01 Rev No 0
FORM : M 01 Page 3 Of 2
Date:10-Jan-2020
 Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

Grade /
Percentage

6/10/2021

79780664095
79788408909

Reason for S/off

end of the contract

end of the contract
end of the contract
end of the contract
end of the contract
transfer to another position

[email protected] / +7 978 847 53 64

ion background security check Form M02 at the

GAS

Gas

ME B/C

No

No

No

No

No

No

No
No

press my willingness to be examined.

er is final.

the course of my employment and cannot be

ng the evaluation process/PJF

Ed 01 Rev No 0
FORM : M 01 Page 4 Of 2
Date:10-Jan-2020