B.P. MARINE ACADEMY (APPROVED by D.G. SHIPPING, GOVT. of INDIA) Sai Pooja Chambers, Sector

B.P. MARINE ACADEMY (APPROVED BY D.G. SHIPPING, GOVT. OF INDIA) Sai Pooja Chambers, Sector – 11, CBD Belapur, Navi Mumbai : 400 614. Tel.No: (91) 22-27574082 / 27565179 / 27562179 Fax No.: (91) 22-27579103 Email: [email protected]/[email protected] Website: www.bpmarineacademy.in DECK & ENGINE (G.P) RATING Affix your recent Passport Size Attested Coloured CERTIFICATE COURSE IN MARITIME CATERING (Saloon Rating) Photograph (40 mm x 30 mm) DIPLOMA IN NAUTICAL SCIENCE (IGNOU-DGS)

B.Sc. NAUTICAL SCIENCE (MUMBAI UNIVERSITY)

HND IN NAUTICAL SCIENCE / MARINE ENGINEERING STC (MCA–UK)

HND IN NAUTICAL SCIENCE / MARINE ENGINEERING GCNS (MCA–UK)

ELECTRO TECHINICAL OFFICER COURSE (COMPANY REQUIRMENT)

HND IN BUSINESS ( STC – UK )

HND IN COMPUTING ( STC – UK) APPLICATION FORM No : Name in Full 1 (In Block Letters as per 10th Std. Cert.) : 2 Date of Birth : Age : Years : Months :

3 Place of Birth :

4 Local Guardian’s Name : Address And Relationship : Relationship : Tel. No. : STD Code : 5 Communication : Address with Tel. No. (Mention STD Code) Tel. No. : STD Code : and PIN Code : 6 Permanent Address :

Tel. No. : STD Code :

7 Nationality : 8 Passport No. (If Any) : Place of Issue : 9 Father’s Name : Occupation :

10 Academic Qualification : Year Passed Overall % English % P.C.M % Board/University

Class X / Equivalent :

Class XII / Equivalent :

BSc. / B.E. / B.Tech : And Others ( ) :

11 Swimming : (Yes / No) Hobbies : 12 Physical Fitness : Height Cms. --- Weight Kgs. 13 Eyesight : Normal (Yes / No) Colour Blindness (Yes / No) 14 Chest : Unexpanded Cms. --- Expanded Cms 15 Identification Marks : 16 Extra Curricular Activities :

17 Are you a ward of a : (Yes / No) CDC No. of the Seafarer Guardian : 18 Are you Sponsored by any : (Yes / No) Company Shipping Company Name : (Attach Sponsorship Letter)

JOINT DECLARATION BY THE APPLICANT AND PARENT / GUARDIAN

We hereby declare that all the information furnished in this application is true and correct to the best of our knowledge and belief. The original Certificates will be produced for verification at the time of admission. In the event of any information furnished by us is found to be incorrect or false, we agree to rejection / termination of the candidature / admission and forgo any claim whatsoever.

Date : Signature of the Applicant : .

Place : Signature of the Parent / Guardian : .

Note : Kindly submit 2 recent photographs & attested copy of all certificate along with application. Enclosures : (Please mention Documents you have enclosed) 1. 2. 3. 4. FOR OFFICE USE ONLY (THIS SHOULD NOT BE FILLED BY APPLICANT)

Registration No. and Date:______Scrutinised By:______(As per STC-UK Guidelines) Section Notice Sent On :______

Date of Reporting :______

Medical Test Report : Fit Unfit

Selected Rejected Waitlisted

Verification of Original Documents:______

Payment Details______Signature:______