Amazon Vessel Management Private Limited (LIC No.RPSL-Mum-297)

Amazon Vessel Management Private Limited (LIC No.RPSL-Mum-297) (Agents of Langton Shipmanagement Ltd.) Our Principal’s Website : www.amazonmaritime.com Application Form / Personnel Date Update Form

Post applied for : Willing to accept lower rank ? Yes No. Available From : / /

(A) PERSONAL PARTICULARS (AS IN PASSPORT) First Name : Middle Name Last Name / Surname Nationality : Date of Birth Place of Birth

Weights Smoker/ Yellow Fever Union Height (In KGS) Nonsmoker Membership (In CMS) Blood Group Veg / Non – Veg DOI DOE Batch / LOT No. YES NO Boiler Suit Size : MED / Shoe Size : LARGE/XL/ XXL

Permanent Address : Local Address :

City : Tel. : City : Tel. : Post Code : Mobile : Post Code : Mobile : Email :

Document No. Date of Issue Place of Issue Date of DD/MM/YY Expiry DD/MM/YY Passport : County Seaman’s Book (CDC) : National Seaman’s Book (CDC) : Norwegian Seaman’s Book (CDC) : Liberian Seaman’s Book (CDC) :Panamanian Seaman’s Book (CDC) : Marshall Island Other (CDC) : Valid US Visa “C1/D” Yes / No Date of Expiry : Passport ECNR : Yes / No Australian Maritime Crew Visa Yes / No Date of Expiry

Next of kin : Relationship : DOB : Alternate next of kin : Relationship : (in case of family joining) Address : Tel.

………. Family Data ……….

Relationship First Name Last Name DOB Passport No. Place Issue Valid until Spouse Child M / F Child M / F  Indicate Type of Valid Visa : USA CANADA BRAZIL UK OTHERS Anniversary Date :

 Please check if visa is valid for the tenure on board. Form No. : AVMPL / 01 / 2014 REV. NO. : 00 / 2014 Applicant’s Signature ______(B) Education / Other Qualifications : Educational Qualification 10 + 2 / Degree Institution / Year of Passing Result Grade University (1st, 2nd , 3rd or A.B. C. ect)

PRE–SEA TRAINING/APPRENTICESHIP/MARINE ENGINEERING/NAUTICAL DEGREE OR DIPLOMA Pre – Sea Training Training Institution From – To Result Grade / Company Name (1st, 2nd , 3rd or A.B. C. ect)

CERTIFICATE OF COMPETENCY : Highest Competency Certificate Held Date of Passing Examination Issuing Authority Grade Certificate No. DOI Place Issued Valid Until National (Country) Liberian Panamanian Marshall Island Norwegian Hong Kong Other GMDSS GMDSS (Endorsement )

LIST OF S.T.C.W. / OTHER COURSES DONE Courses Cert. No. Date of Issue Place of Issue 1) FPFF / Advance Fire Fighting 2) Proficiency in Survival Craft & RB / PST 3) Elementary/Medical First Aid/Medicare 4) PSSR 5) CTFC / CHEMCO 6) OTFC / TASCO 7) FTFC / GASCO 8) LCHS : (Management / Operational) 9) Ship Maneuvering Simulator Course 10) Radar Obserever Course / ARPA 11) Radar Simulator Course / RANSCO 12) BTM / BRM 13) ISPS (SSO) Course 14) NIS Familiarization Course 15) C.O.C. Revalidation Course 16) INDOS NO (Mandatory Requirement) 17) Other (Specify)

Dangerous Cargo Certification : 1.Endorsement on NATIONAL Certificate Level Number DOI Place Issued Valid Until Petroleum Liquified Gas Liquid Chemicals 2. Other Endorsements

Applicants Signature ______. (‘C) SEA SERVOCE : (Start From Last Vessel Served) Name of the Company Name of the Vessel Flag of Type of Engine make & model & BHP/RW (For Engineers) DWT (D) Rank From To dd/mm/yy Total M/D Vessel Vessel Cargoes Carried (For Deck Officers) GRT (G) dd/mm/yy Non Amazon Management Vessels

Remarks :

Sea Service with Amazon Management Vessels (D) Experience Matrix of Engineer Officer Please makr ‘Y’ against your rank in the cell, if that experience is applicable to you S. Crane Make C/E 2/E 3/E 4/E E/O Any Breakdown experience / No. Remarks Experience on Deck / Cargo Machinery 1 Haaglund 2 Liebherr 3 IHI 4 Mitsubishi 5 NMF 6 Atlas 7 BLM 8 MacGregor 9 Any Other Grab Make 1 SMAG Peiner 2 ORTS Experience on Reefer Machinery / Reefer Container 1 Direct System 2 Indirect System 3 Carrier Transicold 4 Thermoking 5 Daikin 6 Mistubishi 7 Any Other Experience on Oil / Chemical / Gas Tankers 1 Framo Pumps 2 Centrilina Pumps 3 Steam Turbines 4 Any Other Experience on Propulsion System / Manoesuvering System 1 CPP 2 Bow/Stem thruster 3 Twin Screw 4 NOR Control 5 Kongsberg 6 Any Other Experience on Auxilliary Engines 1 Yanmar 2 Daihatsu 3 Sulzer 4 MAN B&W 5 Cummins 6 Caterpiliar 7 Pielstik 8 Volvo Penta 9 Any other S. No. Crane Make C/E 2/E 3/E 4/E E/O Any Breakdown experience / Remarks Experience of major overhaul / breakdown 1 Drydock 2 M/E Turbochargar 3 M/E Governer 4 M/E Cyl.Liner 5 Thrust Block 6 A/E Crankshaft 7 Alternator overhaul 8 Steering Gear 9 Any other Experience in Disaster Management 1 Grounding 2 Collision 3 Oil Spill 4 Crank Case Explosion 5 Scavenge Fire 6 Engine Room Fire 7 Cargo Fire 8 Abandon Ship 9 Steering Failure 10 Any Other Experience in PMS 1 AMOS 2 TM Master

Applicant’s Signature ______(E) Experience Matrix of Engineer Officer Please makr ‘Y’ against your rank in the cell, if that experience is applicable to you S.No. Description M CO 20 30 Cdt Any Breakdown or incident experience / Remarks Have you called in the following areas ? 1 Indian Ocean 2 Pacific Ocean 3 North Atlantic Ocean

4 South Atlantic Ocean 5 South China Sea 6 Austratian Walers 7 Mediterranean Sea 8 Black Sea 9 English Channel / North Sea 10 Singapore Strails 11 Panama Canal 12 Suez Canal 13 Kiel Canal 14 Great Lakes 15 16 17 Chemical / Product Tanker Tank Cleaning experience 1 Cleaned tanks after carriage of veg.oil ? 2 Cleaned tanks for Methanol carriage ? 3 Cleaned tanks MEG or similar cargoes? 4 Cleaned tanks for Veg Oil carriage ? 5 Cleaned tanks for Jet Fuel ? 6 Changed from duty to clean products?

Gas Tanker Experience 1 Fully Refrigerated vessel 2 Fully pressurised vessel 3 Partially refrigerated vessel Oil / Product / Chemical Tanker Experience 1 Inert Gas vessel 2 Crude Oil Washing 3 Inert Gas purging 4 Cleaning crude oil tanks for hot work 5 Framo Pumps operation 6 Cargo Heating 7 Framo Pump damage 8 Over / Under pressurization of tanks 9 Cargo contamination

Sr. Description M CO 20 30 Cdt Any Breakdown or incident experience / Remarks

Bulk Carrier Experience 1 Hose test for hatch covers 2 Bilge valve testing 3 Ballasting of cargo hold 4 Disposal of cargo residues 5 Draft survey cargo calculations 6 Over / Under pressurization of Holds 7 Cleaned Holds for Grain carriage ? 8 Cleaned Holds for Fertilizer carriage ?

Experience of major overhaul / breakdown 1 Drydock 2 Windlass damage / Loss of Anchor 3 Sterring Gear failur

Experience of Special circumstances & Disaster Management 1 Grounding 2 Coilision 3 Oil Spill 4 Crank Case Explosion 5 Scavenge Fire 6 Engine Room Fire 7 Cargo Fire 8 Abandon Ship 9 Steering Failure MARKS MARINE RADIO PVT.LTD 10 Freezing Weather 11 Heavy weather / TRS 12 Fog / Restricted visibility

Experience in PMS 1 AMOS 2 TM Master

Applicant’s Signature ______(F) GENERAL :

(A) Have you ever been denied a foreign visa or been deported from any country ? Yes / No. If yes, state which country and reason (if known) : (B) Have you been the subject of a court of enquiry or involved in a martitime accident ? Yes / No. If yes, please attach details. (‘C) Have you ever signed off a ship due to medical reason within last 3 years? Yes / No If yes, please provide following details :

Name of vessel Date of occurrence Place of occurrence

Reason for sign off :

(D) Last drawn salary in USD :

(E) References: Please give referees frin two recent employers who we may contact for references:

Reference 1 Reference 2 Name of Company Name of Person to contact Address

Country Telephone

I Do hereby declare that all information furnished is true to best of my knowledge and belief.

Received acknowledgement of Application form

Date : ______Rank : ______Applicant Signature : ______(G) For Office use only

Amazon Vessel Management Private Limited (Lic No.RPSL-Mum-230) (Agents of Langton Ship Management Ltd) Our Principal’s Website : www.amazonmaritime.com

SHIP’S STAFF INTERVIEW FORM

STAGE I Name of Candidate ______Date : ______

Rank Applied For : ______Location of Interview:______

Interview Method (Physical/Telephone/Video Conference):______

This form shall be used to document the observations made during the interview. The interviewer may provide his recommendations for additional training if required.

For items marked ‘Poor’ Please give your comments. A. Appearance (Character) V.GOOD GOOD S’FACTORY POOR N/A 1. Dress 2. Grooming 3. Body language 4. Communication skills Comments if any :

Professional knowledge V.GOOD GOOD S’FACTORY POOR N/A 1. Navigation and Watch keeping 2. Cargo Work 3. Technical knowledge 4. Safety awareness 5. Engineering Knowledge 6. Awareness of regulations

Comments if any : ______

Result of Interview : ______Suitable/Not suitable for employment ______Suitable For Vessel Type : ______Rank:______Interviewed By Name ______Signature ______(H) FOR OFFICE USE ONLY

STAGE II (Checked by : Personnel Office) Name : Sign Documentation Checks

a) Copies of all STCW certificate received ? Yes / No b) Copy of all valid Certificates of Competency including Endorsements received ? Yes / No c) Copy of National or Main Certificate of Competency verification certificate received ? Yes / No d) Copies of Passport including all valid visas received ? Yes / No e) Copies of Seaman’s Book including all pages containing sea service revived ? Yes / No f) Copies of pre-joining medical test received ? Yes / No g) Copies of Vaccination Book received ? Yes / No

Comments regarding non-receipts : ______

STAGE III (Assessed By : Marine / Tech. Superintendent / Manager / Deputy General Manager / General Manager)

Name : Sign

Comments : ______

______

Office Add: 216-B WING, SECOND FLOOR, SAI CHAMBER, PLOT NO.44, SECTOR 11 CBD BELAPUR (E) NAVI MUMBAI-400614. TEL:- 022 65263121/+91 09167250160