Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Rank
Employment Code Approved
Surname Self Name Father's / Middle Name Date of Birth Place of Birth Religion
Passport
Indian CDC
US Visa C1/D
Contact Details
Present Address Permanent Address
Relationship Surname Name Date of Birth Passport No. Issue Date Expiry Date Place of Issue
Page 1 of 4
Certificates STCW Reg. Grade Cert.No. Issued on Issued at Validity
Certificate of Competency
Endorsement to Certificate of Competency
GMDSS (GOC)
Watchkeeping Certificate
Tanker Endorsement (Oil Level 1 / Level 2)
Chemical Endorsement (Level 1 / Level 2)
STCW Certification
Advanced Fire Fighting
Proficiency in Survival Craft & RB
Medical First Aid / Master's Medicare
Personal Safety & Social Responsibility
Personal Survival Techniques
Fire Prevention & Fire Fighting
Elementary First Aid
Advanced Tanker Safety (TASCO) Petroleum
Advanced Tanker Safety (TASCO) Chemical
OTFC
CTFC
Automatic Radar Aids
Radar Observer
Radar Simulator
Revalidation Course
Other Certification
Ship Security Officer / ISPS
Bridge Team Management (BTRM / BRM)
Bridge Simulator
Engine Room Simulator
Liquid Cargo Handling Simulator (LCHS)
Inert Gas Systems
Crude Oil Washing
FRAMO
ECDIS
ISM Code
English-Speaking Course
Auditors Course
INDOS
Yellow Fever Vaccination
Certification as mentioned above has been checked for accuracy and authority.
Page 2 of 4
Details of Sea Service Ref :
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* Please do not give the Manning agents' references in the 'Operators' column, but instead give details of the actual vessel operators.
** If one page is not enough, please make copies of this page and attach to the application.
Page 3 of 4
Ref : 0
Deck Officers
Cargoes Carried :
Trading Pattern :
Engineer Officers
Type of Machinery :
:
Pre-Sea Training :
Has the applicant has ever signed off from a vessel on medical grounds? If yes, please furnish details.
Yes No
Name of Vessel Date Signed Off Reason / Brief Description of Illness / Injury / Accident
Have you visited the doctor in the last 12 months for any surgery / illness? If yes, please furnish details
Yes No
Were you ever denied a foreign visa? If yes, please furnish details. Yes No
Do you have any history of accidents during your sea service ? Yes No
If yes, please give details on a separate sheet of paper.
I hereby declare that all the details given in this application are true. Further, I understand that the company can
hold me liable and refuse any claim for treatment, cost or any other Insured benefits if a complete and
true statement of all previous illnesses has not been given.
Application details including sea service and reference checks are verified.
Remarks