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NAUTICAL MARINEMANAGEMENT

SERVICES PVT LTD

D.G. Approved LIC NO: RPSL-MUM-037

Application Form/Personnel data Update Form (Officers)

PRINCIPALS:

INDOS NO:
Post applied for: / Willing to Accept lower Rank: Yes/No / Available from:
First name: / Middle Name: / Surname:
Nationality: / Date of Birth: / Place of Birth:
Height: / Weight in KGS: / Smoker/Non-Smoker:
Boiler suit size: / Shoe size: / Yellow fever valid till:
Permanent Address:
Tel No: Mobile No: Email: Nearest Airport :
Address in Mumbai:
DOCUMENT NAME / DOCUMENT
NUMBER / ISSUED DATE / EXPIRY DATE / ISSUING ATHOURITY / ISSUED PLACE
PASSPORT
CDC INDIAN
CDC LIB
CDC PANAMA
Others
Valid US Visa “ C1D”: Yes/No Valid Until: Passport ECNR Yes/No
Next of kin: Relation: DOB: Married/Single:
Address:
Tel:
Mobile: email:
Wife PPNo/DOI/DOE
NO OF Children:
Details of Children (Age, Sex) :
ISSUED BY / GRADE / CERTIFICATE NUMBER / ISSUE DATE / EXPIRY
DATE / REVALIDATION
INDIAN
UK
AUSTRALIA
SINGAPORE
LIBERIAN
PANAMA
OTHERS

DETAILS OF CERTIFICATES OF COMPETENCY

GMDSS (DECK OFFICERS ONLY)

Issuing Authority / Grade / Number / DOI / DOE / Revalidated
ENDORSMENT / LEVEL / NUMBER / DOI / POI / DOE
PETROLIUM
LIQUID GAS
CHEMICAL
GMDSS

STCW-95 COURSES

Course / Number / Place of issue / VALID
From To
FPFF / AFF
PST / PSC+RB
EFA / MFA / MEDICARE
PSSR
OTFC / TASCO / ST
GTFC / GASCO
CTFC / CHEMCO
ISPS / SSO
ROC
ARPA
BTM
SHIP HANDLING
ENGINE ROOM SIMULATOR
OPA 90
COW/IG
ISM
FRAMO
REFRESHER & UPGRADATION
TURBO

EDUCATIONAL QUALIFICATION

NAME OF THE INSTITUTE / DEGREE/CERTIFICATE HELD / YEAR / REMARKS

GENERAL:

A. HAVE YOU BEEN DENIED FOR ANY VISA?YES/NO

IF YES, STATE WHICH COUNTRY AND WHY

B. DO YOU HAVE ANY MEDICAL PROBLEM?YES/NO

IF YES, STATE WHAT AND SINCE WHEN

C. HAVE YOU EVER BEEN SUBJECT TO COURTOF INQUIRE YES/N0

□ Grounding □ Stranding □ Major Fire

□ Major Engine Breakdown Necessitating Towage □ Oil Pollution Incident

Last Drawn Salary:

REFERENCES

SNO / NAME / COMPANY /DESIGNATION / TELEPHONE/ADDRESS
1
2
222

Any additional Information you wish to provide

I do hereby declare that all information is true &complete to best of my knowledge.

Date: Signature______

Copies of Documents Received on and checked by ______

Application forwarded to principals on ______

Comments received from Principals on ______Accepted / Rejected

Company Reference obtained on & by ______

Assigned to join vessel ______

NAME OF COMPANY / NAME OF VESSEL / TYPE / FLAG / RANK / GRT/DWT / ENGINE/BHP (ENGINEERS) / FROM / TO / M/D

SEA SERVICE RECORD