1. WPIF – M/01 20TH APRIL 2015 Rev - 07
Application Form
Engineering Officers
Section1 Position
Position Applied for Chief Engineer
Lowest Position Acceptable No
Date of Availability 25/10/ 2016
Section2 PersonalDetails
Family name / Surname Poshchupailov
First Name / Given Name Aleksandr
Date & Place of Birth 09/02/1963, Feodosia, USSR
Nationality Russian Federation
Permanent Address 21/331, Sadovaya st., Tver, Russian Federation
Present Address 21/331, Sadovaya st., Tver, Russian Federation
PPE information SAFETY SHOES SIZE 44 COVERALL SIZE 3XL
Blood Group B(III) Rh-
Physical Information HEIGHT 172 WEIGHT 105
Present Contact Number n/a
Mobile Number +7 978 022 – 41 - 04
SKYPE ADDRESS alexpaylov963
Email Address alexpaylov@yandex.ru
Nearest Airport (and Distance) Simferopol 120 km
Section3 Passport
Country of Issue Russia
Date Issued 04/03/2013
Place Issued FMS 69001, Tver, RF
Passport Number 73 0210017
Passport –Expires 04/03/2023
Section4 Seaman Record Book / Seaman ID
Issuing Country & Place Russia, Novorossiysk Date Issued Expiry Date
Number MK 0024519 04/04/2012 Permanent
Seaman ID card RUS 0060559 30/03/2012 29/03/2017
Section5 Next of Kin
Full Name / Relationship Rakhmanova Olga, wife
Any dependents/ Children (incl age ) Rackmanov Anatoliy, sun, 23 y.o.
Address 98100,18/2 Zemskaya st. ,Feodosia, Ukraine
Contact Number +38 (06562) 3-29-35
2. WPIF – M/01 20TH APRIL 2015 Rev - 07
Section6 STCW95 Highest Certificate ofCompetency / Licence Held
Class /
Grade/Capacity
Issuing Country Certificate No. Date Issued Expiry Details of Limitations
First Class/3000 kW
or more / Chief
Engineer
Russian
Federation
2035500676 23/08/2016 05/07/2021 UNLIMITED
Section7 STCW95 Dangerous CargoEndorsements
Petroleum…………….
Liquefied Gas……….
Liquid Chemicals…….
Certificate No. Date Issued Expires Details of Limitations/ Grade
Section8 STCW95 relatedCourses Attended and Certificates Obtained
Name of Course / Certificate STCW Code Place Issue Date Cert No Expiry Date
Basic Safety Training A-VI/1 Astrakhan,
Russia
05/07/2016 0532298 05/07/2021
Basic Sea Survival / Personal Survival
Techniques
A- VI/1-1
Fire Prevention & Fire Fighting A-VI/1-2
Elementary First Aid A-VI/1-3
Personal Safety & Social Responsibility A-VI/ 1-4
Proficiency in Survival Craft & Rescue
Boats
A-VI/ 2-1 Astrakhan,
Russia
06/07/2016 0596406 06/07/2021
Proficiency in FAST RESCUE BOATS A-VI/ 2
Advanced Fire Fighting A-VI/ 3 Astrakhan,
Russia
07/07/2016 0494056 07/07/2021
Medical & First Aid A-VI/ 4-1 Astrakhan,
Russia
12/07/2016 0415101 12/07/2021
Proficiency in Security Awareness A-VI
Proficiency in Designated Security
Duties
A-VI/6 Astrakhan,
Russia
13/07/2016 0597516 13.07.2016
Medical Certificate / HEALTH
Certificate
MLC
Compliant
Astrakhan,
Russia
19/09/2016 N/A 19/09/2017
Drug / Alcohol test certificate Astrakhan,
Russia
19/09/2016 N/A 19/09/2017
YELLOW FEVER Odessa,
Ukraine
22/06/2011 22/06/2021
ISM Code A.1441 (18)
Engine Room Resources Management
( Operational Level / Management level )
A-III/1,A-III/2,
A-III/3,A-VIII/2
HELM(leadership and management skills ) A-II/2, A-III/2
Carriage of dangerous and hazardous
substances
B-V/b and
B-V/c
Astrakhan,
Russia
22/07/2016 22/07/2021
3. WPIF – M/01 20TH APRIL 2015 Rev - 07
Section9 OFFSHORE INDUSTRYCOURSES
Please enter below any other certificates held or courses done,ie offshore, DP certs etc or Any other not already mentioned
Name of Course / Certificate APPROVALS Place Issue Date Cert No Expiry
BOSIET / FOET
HUET
OFFSHORE MEDICALS
( UK, NORWAY or NETHERLAND )
Re-Breather training
Initial Standby vessel crews training ( ITSO )
CAA (Civil Aviation Authorities – Helicopter)
Advanced Medical Aider ( AMA )
HLO
BASIC H2S TRAINING McDermott
Middle East
Inc.
Sharjah,
UAE
16/04/2016 20131-1 17.04.2017
MARLIN’s English Test Score: 93% Sevastopol,
Ukraine
26/07/2011 20BB76CF9
F724543
Permanent
IELTS-English TEST http://www.ielts.org/test_centre_search/search_results.aspx SCORE
PMS maintenance system – Confirm that you are Familiar with its use ( YES / NO )
Yes
DEEP WATER ANCHOR HANDLING EXPERIENCE ENTER DEPTH IN METERS 40 – 100
DP Maintenance Courses Odessa Maritime
Training Centre
Odessa,
Ukraine
22/06/2011 0069/
2011
Permanent
HIGH VOLTAGE COURSE
Dynamic Positioning Induction Course
Dynamic Positioning Simulator Course
Dynamic Positioning Operators
CERTIFICATE
Full or
Limited
Dynamic Positioning Log book Details
Section10 Hours done with various DP system
SYSTEM DETAILS Approx Hours as SDPO / Approx Days
in case of Senior ETO / Senior Engineer
Approx Hours as DPO / Approx Days
in case of Junior ETO / Junior Engineer
APPROXIMATE Total DP Hours in Various Operations
SAT DIVING CABLE LAYING
AIR DIVING SURVEY
ROV PIPE LAYING
WELL STIMULATION/ INTERVENTION/
ACTIVATION
DRILL SHIP / SEMI SUB
AHTS 1000 PSV 200
FPSO SHUTTLE TANKER
CONSTRUCTION ROCK DUMPING / MATTRESSING
CORING TRENCHING
HEAVY LIFT ACCOMMODATION/ GANGWAY
4. WPIF – M/01 20TH APRIL 2015 Rev - 07
Section 11 Medical History
YES NO
1. Have you ever signed off a ship due medical reason and been hospitalised? X
2. Have you ever been signed off the vesseland repatriated due illness? X
3. Have you undergone any medical operations in past? X
4. Have you consulted a doctor during the past 12 months for an illness / Accident X
5. Do you have any health or disability problem now?? X
6. Any Past MedicalCondition – Which May Affect Your Work :- (If Yes Than Please Specify Below) X
7. Do you feel healthy and fit to perform the duties of your designated
position/occupation?
X
8. Are you allergic to any medications?- If Yes,then please identify below X
Allergic to Medications : X
9. Are you taking any non-prescription or prescription medications at present? X
If yes, please list the medications taken, and the purpose(s) and dosage(s):
PRESCRIPTION MEDICATION:
NON-PRESCRIPTION MEDICATION:
If answer to any of above is YES then give further details below or on a separate sheet
NOTE : All our clients have STRICT Alcohol and Drug Policy,
Which means ZERO TOLERENCE for alcohol and drugs
Section 12 General
Yes No
Have you ever been involved in a maritime accident, ie grounding, fire, Explosion, Collision.etc X
Have you ever been the subject of a court of enquiry or involved in a maritime accident X
Have you ever had a professional licence suspended or revoked X
Have you ever been convicted of any criminal offence? X
Have you ever been dismissed due any reason X
If yes to any of above then please full details below or on separate sheetofpaper
Section 13 PROVIDE DETAILS OF YOUR LAST EMPLOYER, IN
ORDER TO OBTAIN CONFIRMATION ON YOUR SEA SERVICES
Name of company ATLANTIC MARITIME GROUP
Name Person to be contacted Port Engineer Mr. Hassan Sharafi
Address P.O.Box:6653, Sharjah, UAE
Tel No Mob : +971 504625758 Fax Fax : +971 6 5260292
Email hassan@amguae.net
Name of company
Name Person to be contacted
Address
Tel No Fax
EMAIL
Section 14 Any other information, you wish to add in support of your application
Section 15 Declaration – MUST BE SIGNED BY ALL APPLICANTS
I hereby declare that the above particulars are true and I authorize you to contact thereferees listed above
And confirm that All my certificates /Licences are Authentic/ SEASERVICE RECORD is ACCURATE / And I confirm
accepting Companies DRUG & ALCOHOL Policy
Signed: Aleksandr Poshchupailov Date:24.10.2016
5. WPIF – M/01 20TH APRIL 2015 Rev - 07
Section16 Recordof Full Sea Service (All Dates to be entered as dd/mm/yy)
Please give full record of sea service STARTING FROM LAST VESSEL FIRST
VESSEL COMPANY Type of Vessel
And Type of
operation in case
of DP vessels
GRT Type of Engines
Or DP System
BHP RANK Sign on
DATE
Sign off
DATE
dd / mm / yy dd / mm / yy
NAUTICAL
TIDE
TIDE WATER ROV DP-2 2367 CAT3512 4 X 1000 Chief Engineer 15/04/2016 15/05/2016
ES THUNDER AMG AHTS,CPP
DP-2
2081 MAK 8M25 2 X 3264 Chief Engineer 14/04/2015 17/05/2015
ALLIANZ
ARISTON
STANFORD
MARINE
OSV
ASD DP-1
1671 WARTSILA 8L20 2 X 2200 Chief Engineer 04/06/2014 07/09/2014
ALLIANZ
ARISTON
STANFORD
MARINE
OSV
ASD DP-1
1671 WARTSILA 8L20 2 X 2200 Chief Engineer 22/01/ 2014 09/04/2014
STANFORD
GOLD
STANFORD
MARINE
PSV,FPP 1094 CAT 3512 2 X 1500 Chief Engineer 12/06/2013 19/09/2013
STANFORD
KITE
STANFORD
MARINE
PSV
ASD DP-I
1387 CUMMINS
QSK60-M
2 x2000 Chief Engineer 03/10/2012 17/12/2012
STANFORD
KITE
STANFORD
MARINE
PSV
ASD DP-I
1387 CUMMINS
QSK60-M
2 x2000 Chief Engineer 16/04/2012 13/07/2012
STANFORD
GOSHAWK
STANFORD
MARINE
PSV
ASD DP-I
1399 CUMMINS
QSK60-M
2 x2000 Chief Engineer 26/10/2011 20/01/2012
CHIPLUN SVITZER
TUG BOAT,
FPP
424
NIIGATA 6L26
HLX 2 x 2241 Chief Engineer 22/09/2010 16/01/2011
SVITZER
MERMAID
SVITZER
ASD TUG
BOAT
305
WÄRTSILÄ
NOHAB
WN8V25
2 x 1999 Chief Engineer 28/05/2010 25/08/2010
SVITZER
NABIH SALEH
SVITZER
ASD TUG
BOAT
332
YANMAR
8N21A
2 x 2282 Chief Engineer 31/10/2009 11/02/2010
GALF
MALLARD
TIDE WATER
ASD TUG
BOAT
411
WÄRTSILÄ
NOHAB
WN8V25
2 x 2000 Chief Engineer 16/04/2009 16/08/2009
OIL PUMA TIDE WATER PSV,CPP 859
YANMAR 6Z-
ST
2 x 2176 Chief Engineer 20/10/2008 14/01/2009
6. WPIF – M/01 20TH APRIL 2015 Rev - 07
DONNELY
TIDE
TIDE WATER
AHTS, CPP
DP-I
1860 MAK 9M25 2 x 4039 Chief Engineer 29/05/2008 27/06/2008
OIL PANTER TIDE WATER PSV, CPP 836
YANMAR 6Z-
ST
2 x 2176 Chief Engineer 24/04/2008 28/05/2008
PLATT TIDE TIDE WATER
AHTS, CPP
DP-I
1857
MAK 9M25
2 x 4039 Chief Engineer 25/01/2008 24/04/2008
OIL TYPHOON TIDE WATER
AHTS, CPP
DP-I
985
WÄRTSIL
NOHAB
WN8V25
2 x 2040 Chef Engineer 22/06/2007 22/10/2007
PATTAROZZI
TIDE
TIDE WATER
PSV
ASD DP-I
1888
CATERPILLAR
2 x 2392 2-nd Engineer 25/04/2007 21/06/2007
PLATT TIDE TIDE WATER
AHTS, CPP
DP-I
1857
CATERPILLAR
9M25 2 x 4039 2-nd Engineer 14/04/2006 17/07/2006
GOLDBLATT
TIDE
TIDE WATER
AHTS, CPP
DP - 2 1800
WÄRTSILÄ
NOHAB
WN8V25,
2 x 3000 2-nd Engineer 03/10/2005 27/01/2006
GOLDBLATT
TIDE
TIDE WATER
AHTS
DP - 2 1800
WÄRTSILÄ
NOHAB
WN8V25,
2 x 3000 2-nd Engineer 26/04/2005 26/07/2005
SCHAARTOR TIDE WATER AHTS, CPP 1142 MAK 6M25 2 x 2038 2-nd Engineer 28/09/2004 05/02/2005
NEFTEGAZ-52
FAR EAST
MARINE
COMPANY –
FEMCO
AHTS, CPP 2723
ZULCERZL
40/48
2 x 3600 2-nd Engineer 20/05/2003 20/10/2003
NEFTEGAZ-52 FEMCO AHTS, CPP 2723 ZULCER ZL
40/48
2 x 3600 2-nd Engineer 06/03/2002 19/09/2002
NEFTEGAZ-52 FEMCO AHTS, CPP 2723 ZULCER ZL
40/48
2 x 3600 3-rd Engineer 19/02/2001 05/06/2001
NEFTEGAZ-16 FEMCO AHTS, CPP 2723 ZULCER ZL
40/48
2 x 3600 3-rd Engineer 28/03/2000 04/08/2000
NEFTEGAZ-16 FEMCO AHTS, CPP 2723 ZULCER ZL
40/48
2 x 3600 3-rd Engineer 31/07/1999 10/11/1999
9. WPIF – M/01 20TH APRIL 2015 Rev - 07
ADDITIONAL INFORMATION SHEET
VESSELTYPE YOU ARE INTERESTEDIN (please list in order of priority)
1.AHTS
2.PSV
3.OSV
4.
5.
MAXIMUM ACCEPTABLE CONTRACT PERIOD(Please indicate below)
3 month +1
Please Quote –Consolidated MINIMUM MONTHLY SALARY( no leave pay ) payable for
time onboard only or Working DAY RATE EXPECTATION( no leave pay) (please quote
below in US$ -preferred or Euro or GBP£ )
350 USD or 300 Euro
Languages Spoken / Written / Understood (1-poor 5-Fluent)
Spoken Written Understood
ENGLISH – MARLINS 93% 5 4 4
DRUG & ALCOHOL POLICY
ALL Our Clients have very strict NO DRUG and ALCOHOL POLICY, Which is required to be
complied with at all times, which means “””ZERO TOLERENCE on ALCOHOL & DRUG”””
Your body must NOT have any ALCOHOL or DRUG substances from the time you board your flight
or commence your travel to join vessel, and Must remain so Until you have completed full contract
and returned to your home Airport / Town
If during the said period you are found under the influence of DRUG or ALCOHOL then ALL
EXPENCES incurred which will include all your travel and recruiting costs, And your relief’s
Travel and recruiting costs, And Any other costs whatsoever incurred due to your NON-
COMPLIANCE will be deducted from your salary, Which will include but not limited to “damage to
vessel her equipments and machineries, loss of charter, and any other costs Directly or indirectly
connected with your NON-COMPLIANCE
Sign &CONFIRM ACCEPTANCE OF ABOVE POLICY………………………………………
FOLLOWING DOCUMENTS COPIES MUST BE SENT TO US- send to us In separate Email
All Certificates / Courses Listed in this form + Licence or Certificate of competency, Any tanker
endorsements, GMDSS showing expiry date in case of Deck Officers, Medical Fitness / Examination
Certificate, Passport Main page, Seaman book or Discharge book Main pages, In case of DPO – DPO Cert,
DP LOGPages
FOLLOWING ADDITIONAL DOCUMENTS will ALSO BE REQUIRED–Send to us in separate email
All short courses certificates ( STCW95 ), SSO certificate, Last 3-5 years ships entries in Discharge book or
Seaman book, Certificate of Equivalent Competency from other flag states
