114 WPIF-MO-01 VGG Application Form

VGG INDIA PRIVATE LIMITED
1st floor, P&G Plaza, CTS 495, Cardinal Gracias Road,

Opp. Chakala Church, Chakala, Andheri (East), Mumbai 400 099
Tel: +91 022 40868000; Fax: +91 022 40868001; Email: enquiries@vggindia.com
APPLICATION FORM
POSITION
POST APPLIED FOR ARE YOU WILLING TO JOIN Y/N
Chief Officer A RANK LOWER IF
CURRENT POSITION IS NOT
AVAILABLE
DATE AVAILABLE 01 June 2017 HEIGHT 172cm
FROM
INDOS NO. 05NL 2022 WEIGHT 72KG
MUI NO. N 035072 SAFETY SHOE SIZE: 9
BOILER SUIT SIZE : XL
PERSONAL DETAILS { Pls Write In Capital Letters}

SURNAME FIRST NAME MIDDLE NAME
JITHU RAJ
NATIONALITY DATE OF BIRTH PLACE OF BIRTH

INDIAN 13-10-1987 CHARUMMOOD, KERALA
PRESENT ADDRESS PERMANENT ADDRESS
ATHIRA, Peroorkarazhma, Charummood P.O., ATHIRA, Peroorkarazhma, Charummood P.O., Alappuzha
Alappuzha Dist. Dist.
Tel No : 04792385537 Tel No : 04792385537

Mobile No: +918089006035 Mobile No: +918089006035
Email : jithuanytime@gmail.com Email : jithuanytime@gmail.com
IDENTITY DOCUMENTS
DOCUMENT PLACE OF ISSUE NUMBER DATE OF ISSUE DATE OF EXPIRY
PASSPORT: Cochin Z3706332 26-04-2016 25-04-2026
US VISA : Chennai H1290980 24-10-2013 22-10-2018
OTHER VALID
VISA:
CDC INDIAN Chennai CH55519 23-08-2008 22-08-2018
CDC PANAMA
CDC LIBERIAN
OTHERS CDC
YELLOW FEVER YES NO ENSURE AT LEAST 2 BLANK PAGES IN YOUR PASSPORT :

YES/NO
DATE DONE : 23-05-2008 CLOSEST AIRPORT : Thiruvananthapuram
DATE OF EXPIRY: 22-05-2018
MEDICAL HISTORY: YES / NO IF YES PLEASE PROVIDE DETAILS OF MEDICAL PROBLEM

:
DETAILS OF LICENSES / CERTIFICATES

GRADE/CLASS OF COC ISSUING CERTIFICATE NO. DATE ISSUED PLACE VALID
COUNTRY ISSUED UNTIL
Chief Mate (FG)- INDIA IFO-18543 07-08-2014 COCHIN 23-06-2020
Indian
WPIF- MO-01 DATE: 12th September 2016 REV: 0 Page 1 of 5

COURSE DETAILS
Course Name Certificate No. Date Of Date of Place Issued By
Issue Expiry Issued
CERTIFICATES FOR ALL OFFICERS / ENGINEERS /CREW - CREW TO HAVE BASIC COURSES
PMA/AFF(R)/03 25-02-2015 Pondicherry PMA
FPFF / AFF
/08-A/2015
MCCR/EMA/ 21-04-2016 Cochin EUROTECH
EFA / MFA / MASTERS MEDICARE
64-16/000371
PMA/PSCRB(R 18/08/2015 Pondicherry PMA
PST / PSCRB
)/09/33/2015
PMA/PSSR 18/02/2015 Pondicherry PMA
PSSR
(R)/22/07/2015
SSO/EMA/Batch 19-12-2013 Cochin EUROTECH
SSO/STSDSD
II/19-13/000399
IMERPAT/RUTD/ 27/08/2016 Patna IMER
RUTC*
23-2016/014
ADDITIONALLY FOR DECK OFFICERS
GMDSS (GOC) GOC-C-2416 24-06-2010 Cochin MMD
GMDSS ENDORSEMENT COC-0002971 19-08-2015 Cochin MMD
ROC 18-10/177 19/02/2010 Cochin EUROTECH
ARPA 18-10/169 25/02/2010 Cochin EUROTECH
RANSCO 26-13/000181 02/09/2013 Cochin EUROTECH
BTM
BRM
ECDIS/EMA/38- 19-12-2013 Cochin EUROTECH
ECDIS
14/000369
**SMSC
ADDITIONALLY FOR ENGINEERS
***BERS
ADDITIONALLY FOR TANKER / CHEMICAL / GAS VESSELS
OTFC /TASCO
CTFC/CHEMCO
GTFC/GASCO
*****ATLGTO
ENDORSEMENT FOR TANKER / CHEMICAL / GAS VESSELS
OIL DCE OPS/ SUP
CHEM DCE OPS/SUP
GAS DCE OPS / SUP
FOR DP / OFF SHORE VESSELS
SDB/05- 26-01- Mumbai BIBBY
DP INDUCTION
439/2012 2012
SDB/01- 31-10- Mumbai BIBBY
DP ADVANCED
674/2014 2014
DPO CERTIFICATE 26600 16-09-2015 London NI
DP TECHNICAL AND MAINTENANCE
H2S SAFETY AND B.A.
****HUET
EMERGENCY BREATHING SYSTEM
841755707130 13-09-2014 Singapore SMTC
BOSIET OPITO approved
9140008
HLO( HELICOPTOR LANDING OFFICER)
RIGGING AND SLINGING( DECK CREW)
OTHER COURSES FOR RATINGS
WELDER /FITTER COURSE
WELDING CERTIFICATE
WATCH KEEPING CERTIFICATE RATINGS
(DECK/ENGINE)
FOOD HYGENE ( CATERING CREW)

MARLINS TEST
* RUTC = REFRESHER AND UPGRADATION TRAINING COURSE
**SMSC = SHIPS MANOUVERING AND SIMULATOR COURSE
***BERS= BRIDGE AND ENGINE RESOURCE MANAGEMENT
****HUET=HELECOPTOR UNDER WATER ESCAPE TRAINING
*****ATLGTO=ADVANCE TRAINING PROGRAMME ON LIQUEFIED GAS TANKER OPERATION
References (Please give the name and address of your current or immediate past employer)
S. NO NAME ADDRESS TELEPHONE NO
1. Mr. Ronald Halani Shipping Pvt. Ltd. 022-26359235

COMPANY VESSEL VESSEL TYPE FLAG D.W.T . VSL TYPE OF B.H.P RANK
/ GRT AGE ENGINES
HALANI SHIPPING DSV GERIMAL St.Vince 2208 25 C/O
PVT. LTD. nt&Grena
DP2 DSV - DPO
dines
SAT diving/
Construction
GLOBAL OFFSHORE MEGHNA AHTSV Indian 1706 02 C/O
SERVICES LTD..
DP1 DPO
GLOBAL OFFSHORE MEGHNA AHTSV Indian 1706 02 C/O
SERVICES LTD..
DP1 DPO
PVT. LTD. DP2 DSV - nt&Grena DPO
SAT diving/ dines
Construction
HALANI SHIPPING DSV GERIMAL DP2 DSV - St.Vince 2208 25 C/O
PVT. LTD. nt&Grena
SAT diving/ JDPO
Construction dines
PVT. LTD. DP2 DSV - nt&Grena JDPO
Air diving/ dines
Construction
PVT. LTD. DP2 DSV - nt&Grena JDPO
Air diving/ dines
Construction
2475 01 2/O
DP2 - JDPO
Construction
ARINA OFFSHORE ARINA SAMURAI Panama
vessel
(MPSV)
Mitsui O.S.K. Lines MOL MARVEL Container Majuro 78316 02 3/0
Mitsui O.S.K. Lines VEGA DREAM Cape Size Tokyo 91468 02 3/0
Bulk Carrier
Mitsui O.S.K. Lines Bahama 59006 02 3/0

s
NEPTUNE ACE Car Carrier

MISCELLANEOUS
A} DECK OFFICERS
Product : Type of Cargo Carried
Chemical: Type of Cargo Carried
Tanker: Type of Pumps
Vetting:
Offshore : Type of Vessels Served On Air Diving / SAT Diving / Construction / Supply / Anchor Handling
DP2. DP1
B} ENGINEERS
Automation: {Type}
Vetting:
C}ELECTRICAL OFFICERS
Automation:{Type}
NOR Control System{Type}
PLC{Type}
D} GENERAL TRADING AREA OF VESSEL
Mumbai High, West Africa
E} OIL MAJOR INSPECTIONS
F}DRY DOCKING EXPERIENCE
G}PRE-SEA TRAINING {Period/Institution}
H} SCHOLASTIC EDUCATION
Acknowledgement Form -License Number: RPSL / MUM / 098- Valid till 30.11.2021
This is to acknowledge that we have received the form from the under mentioned seafarer.
Date: 04-05-2017 Rank: Chief Officer CDC No.: CH55519
Name of seafarer Signature of seafarer Sign & Company Stamp
JITHU RAJ
-
WPIF-MO-01 DATE: 12 th September 2016 REV: 0 Page 4 of 4

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Acknowledgement Form - License Number: RPSL / MUM / 098- Valid till 30.11.2021
This is to acknowledge that we have received the form from the under mentioned seafarer.
Date: Rank: CDC No.:
Name of seafarer Signature of seafarer
Name & Designation Signature Company Stamp

DECLARATION
YES / NO
Have you ever signed off from a ship due to medical reasons? NO
If yes give details
Have you ever suffered from any ailment or disease in the past NO
that is likely to render you unfit for sea service or likely to
endanger the health/well-being of others onboard?
If yes give details
Do you have any bodily defects or deficiencies? NO

If yes give details
Are you currently suffering from any ailment or disease that is NO

likely to render you unfit for sea service or likely to endanger
the healthy / well-being of others onboard?
If yes give details
Are you addicted to alcohol or drug of any kind? NO

If yes give details
Are you suffering from an ailment that requires you to be on a NO

long -term treatment/medication
If yes give details
Have you ever been involved in Grounding, explosion, NO

collision, oil spill or any other maritime accidents or
investigations?
If yes give details
Have you ever been prosecuted or deported due to above or

disciplinary actions? NO
If yes give details
Do you have any objection to VGGI making reference check

with previous employer NO
I hereby declare that all the information provided by me in this application is true and correct to the best of my knowledge and
belief; further that no certificate of competency or License issued to me has ever been Revoked or Suspended.
Name : JITHU RAJ Rank : CHIEF OFFICER
Date : 04-05-2017 Signature :

114 WPIF-MO-01 VGG Application Form

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VGG INDIA PRIVATE LIMITED

1st floor, P&G Plaza, CTS 495, Cardinal Gracias Road,

PERSONAL DETAILS { Pls Write In Capital Letters}

NATIONALITY DATE OF BIRTH PLACE OF BIRTH

Tel No : 04792385537 Tel No : 04792385537

YELLOW FEVER YES NO ENSURE AT LEAST 2 BLANK PAGES IN YOUR PASSPORT :

DATE OF EXPIRY: 22-05-2018

MEDICAL HISTORY: YES / NO IF YES PLEASE PROVIDE DETAILS OF MEDICAL PROBLEM

DETAILS OF LICENSES / CERTIFICATES

WPIF- MO-01 DATE: 12th September 2016 REV: 0 Page 1 of 5

FOOD HYGENE ( CATERING CREW)

WPIF- MO-01 DATE: 12th September 2016 REV: 0 Page 3 of 5

Mitsui O.S.K. Lines MOL MARVEL Container Majuro 78316 02 3/0

Mitsui O.S.K. Lines Bahama 59006 02 3/0

WPIF- MO-01 DATE: 12th September 2016 REV: 0 Page 4 of 5

Chemical: Type of Cargo Carried

Tanker: Type of Pumps

NOR Control System{Type}

F}DRY DOCKING EXPERIENCE

G}PRE-SEA TRAINING {Period/Institution}

WPIF-MO-01 DATE: 12 th September 2016 REV: 0 Page 4 of 4

Name & Designation Signature Company Stamp

WPIF- MO-01 DATE: 12th September 2016 REV: 0 Page 4 of 5

Do you have any bodily defects or deficiencies? NO

Are you currently suffering from any ailment or disease that is NO

Are you addicted to alcohol or drug of any kind? NO

Are you suffering from an ailment that requires you to be on a NO

Have you ever been involved in Grounding, explosion, NO

Have you ever been prosecuted or deported due to above or

Do you have any objection to VGGI making reference check

Name : JITHU RAJ Rank : CHIEF OFFICER

Date : 04-05-2017 Signature :

WPIF- MO-01 DATE: 12th September 2016 REV: 0 Page 5 of 5

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