Career

Application Form

PERSONAL BACKGROUND

PERSONAL BACKGROUND
Name as in Passport
Date/Place of birth Nationality
Home address Tel No.: Mobile No.: Email ID.:
Mumbai address if any Mobile No.:

EDUCATION BACKGROUND

EDUCATION BACKGROUND
Qualification School / College From To Percentage / Grade
TECHNICAL BACKGROUND
Degree / Diploma Institute / College From To Percentage / Grade

IDENTITY DOCUMENTS

IDENTITY DOCUMENTS
Document Country Number Issue date Expiry date Place of issue
Passport Indian
eaman book Indian
Others
Do you hold a US Visa ‘C1/D’ ? YES NO Issue date: Expiry date:
Do you hold Schengen Visa YES NO Issue date: Expiry date:
Indos. No. (for Indians only): Yellow fever: Expiry date:
Union Membership (MUI / NUSI ) Expiry date:

FAMILY DETAILS

FAMILY DETAILS
(IF UNMARRIED KINDLY GIVE DETAILS OF FATHER / MOTHER)
Name Relation D.O.B PPT No. Place of issue Issue date Expiry date ECNR

NEXT OF KIN DETAILS

NEXT OF KIN DETAILS
Full name of kin : Relationship:
Address of next of kin : Tel No.:
Mobile No.:
Email ID.:

CERTIFICATES (HIGHEST CERTIFICATE OF COMPETENCY HELD)
Grade / Class of COC Issuing country Date of passing exam Certificate no. Issue date Placed issued Expiry date

DETAILS OF COURSES & CERTIFICATES FOR OFFICERS
Courses Certificate no. Issued by Issue Date Expiry Date
Advanced Fire Fighting (AFF)
Medical First Aid (MFA) / Medicare
Proficiency in Survival Craft & Rescue Boat (PSCRB)
Personal Survival & Social Responsibility (PSSR)
SSO (Ship Security Officers Course)
ECDIS
BTM (Renewed every 5 years)
ARPA (Automatic Radar Plotting Aid)
GMDSS
Radar Observer / RANSCO Simulator
GMDSS Endorsement
Oil Tanker Familiarization (OTFC) / TASCO
DCE Oil – Support / Operation / Management
Chemical Tanker Familiarization (CTFC) / CHEMCO
DCE Chemical – Support / Operation / Management
Specialized Training Programme On Oil Tanker Operations (STPOTO)
Framo Course
Revalidation Course for Deck / Engine Officers
Refresher & Up Gradation Course for Deck / Engine Officers

DETAILS OF COURSES & CERTIFICATES FOR RATINGS
Courses Certificate no. Issued by Issue Date Expiry Date
FIRE PREVENTION & FIRE FIGHTING (FPFF)
ELEMENTARY FIRST AID (EFA)
Personal Survival Technique (PST)
Personal Survival & Social Responsibility (PSSR)
ISPS Course
Oil Tanker Familiarization (OTFC)
DCE Oil – Support
Chemical Tanker Familiarization (CTFC)
DCE Chemical – Support
Watch Keeping Certificate Ratings (Deck/Engine)
Pump Man Course
Cookery Course
MMD Cookery Certificate
Fitter Course / Class Cert.
Ship Safety Officers Course / Risk Assessment
Ship Maneuvring Simulator
BRM / MRM / BERM (Renewed every 5 years)
Electrical/Electronics for Marine Engineers – Basic / Advance

FOR ENGINEERS (PLEASE PROVIDE DETAILS)
Generators Boilers Cranes Framo ( No. of vessels )

TOTAL SAILING EXPERIENCE
Crude Tankers Product Tankers Chemical Tankers Oil / Chemical Others

OTHER DETAILS

MEDICAL HISTORY (IF THE ANSWER IS YES TO ANY OF THE BELOW, PLEASE GIVE FULL DETAILS AND ATTACH A SEPARATE PAGE IF NECESSARY)
Have you ever signed off a ship due to medical reasons ? YES NO
Have you undergone any Surgery / Accident YES NO
Do you have any health disability problems now ? YES NO

GENERAL
Have you ever been the subject of a court of enquiry or involved in a maritime accident ? YES NO
Have you ever had a professional license suspended or revoked ? YES NO
Do you have any pending criminal inquiry YES NO

BANK ACCOUNT DETAILS
Account Holder’s Name :
Name of bank Account no.
Branch Address :

BOILER SUIT SIZE SAFETY SHOE SIZE
DECLARATION
I hereby affirm that all the information provided by me in this application is true and correct .