Recruitment & Placement Services Manual

Oceanic International Shipping (Pvt) Ltd Application Form of Seafarers (CV)

Revision: 0 Page: 1 of 4 Date: 18.12.2017

Prepared By: Ops/Crew Manager Approved By: MD
FORM no: 02
APPLICATION FORM OF SEAFARERS

Position applied 2ND OFFICER

Surname KUMAR

Name LALIT PHOTO

Date of birth 5/10/1986
Nationality INDIAN

Salary expectation 800 USD

Preffered contract period 6 MONTHS

For Office use only

Date and method of receipt of CV

Acknowledgement of receipt of CV
Is the CV clear enough? Interview date if fixed Remarks

Are the certificate details given in CV

meets the basic requirement

Signature Date

Travel / Identity documents

Date of
Document Document No. Country
Date of issue expiry

Passport - 1 Z3503832 07.O1.2016 06.01.2026 INDIA

Passport - 2 (if applicable

Seaman book - 1 ,040186 25.09.2017 25.09.2021 HOUNDURAS

Seaman book - 2 MUM166558 03.12.2009 02.12.2019 INDIA

Seaman book - 3
Seaman book - 4

Have you been rejected for any visa applied for? IF YES,
indicate country and reasons

CERTIFICATE OF COMPETENCY
CERTIFICATE Number Place Issued Expiry
National COC LK-4686-P HONDURAS 25.09.2017 25.09.2022
Endorsement
Rating forming a part of Nav. Watch
Rating forming a part of Eng. Watch
Electrical / Electronic Eng. Certificate
GMDSS certificate GG037619 U.K. 18.03.2009 23.03.2020
GMDSS endorsement
Liberia endorsement
Panama endorsement
Other
Other
 Recruitment & Placement Services Manual
Oceanic International Shipping (Pvt) Ltd Application Form of Seafarers (CV)

Revision: 0 Page: 2 of 4 Date: 18.12.2017

Prepared By: Ops/Crew Manager Approved By: MD
FORM no: 02

STCW - (78 as amended in 2010) TRAINING CERTIFICATES

CERTIFICATE Number Place Issued Expiry

Basic safety training (A-VI/1 ) BST/0116/OS/0927 GREATER NOIDA

13.04.2017 12.04.2022
Elementary first aid (A-VI/1) 5553/391/014 NEW DELHI
18.01.2014 LIFE TIME
Fire prevention & fire fighting (A-VI/1) 298/029/014 NEW DELHI
23.01.2014 LIFE TIME
Proficiency in survival techniques (A-VI/1) 279/029/014 NEW DELHI
16.01.2014 LIFE TIME
Personal safety & social responsibilities (A-VI/1) 5661/361/014 NEW DELHI
22.01.2014 LIFE TIME
Medical care onboard (A-VI/4 ) MFA/0116/AD/0306 GREATER NOIDA
17.04.2017 16.04.2022
Advanced fire fighting (A-VI/3) AFF/0116/AD/0626 GREATER NOIDA
07.04.2017 06.04.2022

Proficiency in survival craft & rescue boats other than fast rescue
PSCRB/0116/AD/0624 GREATER NOIDA
boats (A-VI/2)
13.04.2017 12.04.2022
Proficiency in fast rescue boats (A-VI/2) FRB/DC/0116/AD/0806 GREATER NOIDA
21.06.2017 20.06.2022
Ships security officer - SSO (VI/5) SSO/0116/AD/0622 GREATER NOIDA 21.04.2017 20.04.2022
STSDS (VI/6) 1276/063/014 NEW DELHI 14.01.2014 LIFE TIME
Radar observer ARPA/OP/0116/AD/0300 GREATER NOIDA 29.04.2017 28.04.2022
Bridge or engine resource management BRM/DC/0116/AD/0806 GREATER NOIDA 03.06.2017 02.06.2022
ISM code
DP course (Induction)
International Ships & Port Facilities Security Code MMC/ISPS/171/390/2011 MUMBAI 14.01.2012 LIFE TIME
Certificate: Ship's Welder
Maritime English Language Course – Support Level
Pre-Sea Training & Deck Rating Programme

MEDICAL HISTORY
Medical pre-employment examination Issued 28.02.2017 Expiry 27.02.2019

Drug & alcohol test Issued 28.02.2017 Expiry 27.02.2019

Yellow fever vaccination Issued 29.11.2017 Expiry LIFE TIME

YES NO
1. Have you ever signed off from a ship due to medical reasons? √

2. Have you undergone any operation / surgery in the past? √

3. Have you consulted a doctor during last 12 months for any illness / accident? √

√
4. Do you have any history of physical or mental problems or any behavioral problems?

(if the answer is YES to any of the above, please give full details and attach a separate signed and dated page if necessary)
 Recruitment & Placement Services Manual
Oceanic International Shipping (Pvt) Ltd Application Form of Seafarers (CV)

Revision: 0 Page: 3 of 4 Date: 18.12.2017

Prepared By: Ops/Crew Manager Approved By: MD
FORM no: 02

GENERAL
YES NO
1. Have you, in any country, been the subject of a court of injury or involved in a maritime accident? √

2. Are you, in any country, presently facing charges for any offence (including transport safety regulatory offences)? √

3. Have you, in any country, during past 5 years been issued any warning letter in relation to violating safety / transport /
disciplinary regulatory issues? √

4. Have you, in any country, had any document, license of competency suspended, cancelled or revoked? √

5. Have you, in any country, been convicted for any criminal offence or been given police diversion for any offence? √

6. Have you ever been convicted in any court of law for any offence involving violence or causing danger to any person, or
√
criminal damage?

7. Have you, in any country, previously had an application for a document or certificate of competency rejected? √

8. Have you ever been convicted in any court of law for any offence relating to controlled drugs, prescribed medicine or alcohol
√
misuse?
9. Have you ever been convicted in any court of law for any offence involving violence or causing danger to any person, or
√
criminal damage?
10. Have you had any ITF / authority exposures? √

11. Is there any other information that is relevant to your application that has not been addressed in the questions above? √

(if the answer is YES to any of the above, please give full details and attach a separate signed and dated page if necessary)

REFERENCES
Name of the Company ARMINA SHIPPING DMCC
Name of the person to contact ASHUTOSH KUMAR
Address SITAMARHI,BIHAR,INDIA
Contact nos 9973065807

Name of the Company

Name of the person to contact
Address
Contact nos

Name of the Company

Name of the person to contact
Address
Contact nos
 Recruitment & Placement Services Manual
Oceanic International Shipping (Pvt) Ltd Application Form of Seafarers (CV)

Revision: 0 Page: 4 of 4 Date: 18.12.2017

Prepared By: Ops/Crew Manager Approved By: MD
FORM no: 02

PERSONAL
Blood group B POSITIVE
Height 182 CM
Weight 95 KG
Eye color BLACK
Hair color BLACK

Coverall size (S/M/L/XL/XXL/XXXL) XXL

Safety Shoes (38/40/42/44/46) 43
Shirt size (S/M/L/XL/XXL/XXXL) XXL
Waist 36 INCH

Mother's name RAMRATI DEVI

Father's name VIRENDRA SINGH
Religion HINDU
Marital status MARRIED
Contact nos 9759998488
Email address LUCKYCHOUDHARY21@GMAIL.COM
Home address VI-NAURANGPUR,PO-RAMPUR(MANIHARAN),DIST-SAHARANPUR, INDIA
Next of kin (Name & relationship)
RITU CHAUHAN & WIFE
Contact nos of next of kin 9720302100
Details of children (if applicable)
Name Date of Birth Male / Female
SHARWIN CHOUDHARY 13.07.2017 Male

I hereby declare that above, including medical history, is true. I accept any investigation with regards to my previous work experience with any party concerned. Further I
confirm that I give the rights to SIS to share my personal data with third party for service purposes or as required applicable legislation. I understand that my working
contract will be cancelled without notifying and I am liable to pay all costs if any submitted information and document are found as false.

RECORDS OF SEA SERVICE

(Please give full details starting from last vessel on which you served)
Signed on Signed off
Name of vessel Flag Vessel type GRT Engine type KW Rank Company name
dd/mm/yy dd/mm/yy
MV.JUMBO EXP. MORONI RORO 3423 CREPELLE 1764 OS 07.12.2007 27.07.2008 MUSANDAM SHIPPING DUBAI
SEA DIAMOND ST.KITTS&NEVIS G.CARGO 6303 B&W 4526 OS 17.07.2009 22.02.2010 NEW PORT CARGO&SHIPPING LLC
BEN MAJID TANZANIA G.CARGO 2853 MITSUBISHI 1490 AB 26.08.2010 13.01.2011 SILVER OCEAN MARINE DUBAI
HARMONY SEAS VANUATU OSV 807 EMD 1455 AB 02.09.2012 28.10.2013 ARMINA SHIPPING
EAGLE RIVER TOGO OSV 1095 EMD 1418 AB 24.01.2014 15.12.2014 ARMINA SHIPPING
H.SUPPORTER ST.VINCENT AHTS 737 EMD 1415 AB 18.03.2015 22.11.2015 ARMINA SHIPPING
HARMONY SEAS VANUATU OSV 807 EMD 1455 AB 17.02.2016 26.10.2016 ARMINA SHIPPING
MV.YARABAH VANUATU OSV 789 EMD 2ND OFF 03,06.2017 13.07.2017 EXCEL MARINE LLC.FZR
I hereby declare that above information provided by me are true and correct. I also understand that my working contract will be cancelled without notifying if any submitted
information are found incorrect.

LALIT KUMAR NAURANGPUR 18.12.2017

Applicant name Applicant signature Place Date
 Company name

USANDAM SHIPPING DUBAI

EW PORT CARGO&SHIPPING LLC
LVER OCEAN MARINE DUBAI
RMINA SHIPPING
RMINA SHIPPING
RMINA SHIPPING
RMINA SHIPPING
XCEL MARINE LLC.FZR
ut notifying if any submitted

18.12.2017
Date