PERSONAL DATA

First Name / Middle Name / Surname
Nationality / Date of Birth / Place of Birth
Post Applied For / Willing to Accept Lower Rank? / Available From:
Permanent Address: / Present Address:
Pin : / Pin :
STD Code : Phone Number : / STD Code : Phone Number :
Email :
Mob :
/ Email :
Mob :
Passport No: / Date of Issue / Place of Issue / Date of Expiry / ECNR / Minimum 4
Blank Pages
U.S. VISA
C1/D : / MUI No: / Membership
Seaman’s Book (CDC) / Number / Date of Issue / Place of Issue / Expiry Date / Remark
Indian
Panamanian
Liberian
Others
License / Grade / Number / Date of Issue / Place of Issue / Date of Expiry
Indian

Liberian

GMDSS
GMDSS COC
Civil Status:
Full Name of Next of Kin: / Relationship:
Address of Next of Kin:
Phone No.:
Height : Cm : / Weight : Kg :
Boiler Suit Size ( S , M , L , XL , XXL) : / Shoe Size (6, 7, 8, 9, 10, 11) :
Family
Data / Name / D.O.B / PPT.No. / D.O.I / Place of Issue / D.O.E / ECNR
Wife
Child Male
Child M/F
Child M/F
* Tick Validity Date / Visa / USA (B1/B2) / UK / Australia / Brazilian / Others
Details of Courses & Certificates / Number / Date of Issue / Date of Expiry / Issued by
STCW Courses:
Basic Fire Fighting (BFF)
FPFF(Refresher)
Proficiency in Survival Technique (PST)
Proficiency in Survival Technique (Refresher)
Elementary First Aid (EFA)
Personal Survival & Social Responsibility (PSSR)
PSSR (Refresher)
Advanced Fire Fighting (AFF)
Advanced Fire Fighting (Refresher)
Proficiency in Survival Craft & Rescue Boat (PSCRB)
Proficiency in Survival Craft & Rescue Boat (Refresher)
Medical First Aid (MFA)
Medicare
Medicare(Refresher)
Radar Observer / ARPA
Radar Simulator (RANSCO)
Ship Handling Simulator
Refresher and Updation Training for Masters
Maritime Labour Convention-2006
Tanker Vetting Inspection
Risk Assesment Course
Incident Investigation Course
Ship Safety Officer Training Course
Enclosed Space Entry Procedure
Shore-Side Safety Management System Training
Ship Manoeuvring Simulator
ISM course
Tanker courses:

Other Courses:

Dangerous Cargo Endorsements / Nationality / Level Of Training / Number / D.O.I / Place of Issue / D.O.E
Pre Sea Training / Apprentice ship
Name of Institute / College / From /

To

/ Type of Degree

Page 3 Previous Sea Service (Commencing from Last Vessel) ( PLEASE FILL THE GRT/KW AS PER STCW REQUIREMENT) (1KW = 1.37 BHP)

Sr.No. / Name of Company / Name of Vessel / Type / GRT / KW / Engine type / UMS
Y / N / Rank / From / To / Total MM/DD / Reason for S/OFF
1
2
3
4

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