FPD 02 Rev No 1 Date: 01 Jan 2013 Page 1 of 4

Application form for Ratings

508,Mayuresh Cosmos, Tel : +91 22 27563580 PHOTO Sector-11,CBD Belapur,, Fax : +91 22 27563581 Navi Mumbai-400614, Maharashtra, India. E mail: [email protected].

Brukaan ID No: Position Applied for : Are you willing to accept a lower rank ? YES / NO Date of Availability: / / PERSONAL DETAILS 1. GENERAL Name: (Last Name) (First Name) Date of Birth: Place of Birth: Nationality: Indian Permanent address:

Post code:  No.: E-Mail address: No.: Present address:

Post code:  No.: Civil Status Single / Married / Separated / Divorced / Widowed : Height : in cm Weight : Waist Size: BMI: Boiler Suit Size : Shoe Size Food: Veg./ Non Veg 2. FAMILY DETAILS. Full Name of Next of Kin : Relationship :

Post code: Contact telephone numbers:  No.: No.: Date of Family Data Name Last Name D.O.B Anniversary Wife Child (M/F) Child (M/F) Child (M/F) 3. MEDICAL HISTORY (a).Have you ever signed off from a ship due to Medical reasons,(If Yes give details) Yes / No Name of the Vessel : Date of Occurrence :

Brief description of Illness / Injury / Accident :

(b). Did you suffer or Are you Presently suffering from any disease likely to render you unfit Yes / No for service at sea or likely to endanger the Health of others on board. (c). Are you addicted to alcohol or drugs of any kind? Yes / No (d).Have You suffered from Following? Malaria Diabetes Epilepsy Nervous Disability Hepatitis of any kind Yes / No Yes / No Yes / No Yes / No Yes / No (e) Did You ever undergo psychiatric treatment? Yes / No

FPD 02 Rev No 1 Date: 01 Jan 2013 Page 1 of 4 TRAVEL DOCUMENTS & VISA Place of Date of Passport No: Date of Issue ECNR Blank Pages Issue Expiry

Union Membership No. D.O.E. U.S.VISA

Any Other VISA

ACADEMICS & PROFESSIONAL QUALIFICATIONS 1. EDUCATIONAL BACKGROUND. School / College From To Highest Qualification attained.

2. PRE SEA TRAINING / APPRENTICE SHIP. Name of Institute / College From To Grade / Marks

3. DETAILS OF COURSES & CERTIFICATES. Course Type CERTIFICATIONSNUMBERS & COURSESDATE OF DATE OF ISSUED BY 1. CDC DETAILS. ISSUE EXPIRY FireSeaman’s Prevention Book & Fire Fighting(FPFF)Number Date of Issue Place of Issue Date of Expiry IndianProficiency in Survival Craft & Rescue Boat LiberianProficiency in Survival Technique(PST) PanamanianElementary First Aid (EFA) MarshallPersonal IslandsSurvival & Social Responsibility BahamasOil Tanker Familiarisation (OTFC) IOMChemical Tanker Familiarisation (CTFC) OthersGas Familiarisation (GTFC) 2.Watch INDOS Keeping DETAILS. Certificate as Rating. Cookery Certificate AB / Motorman Course Elementary English Yellow Fever Others 4. DANGEROUS CARGO ENDORSEMENTS Types LEVEL NUMBER DATE OF ISSUE PLACE OF ISSUE D.O.E Oil Chemical Liquified Gas FPD 02 Rev No 1 Date: 01 Jan 2013 Page 2 of 4 PREVIOUS SEA SERVICE (Date commencing from Last Vessel) DWT Name of Owners / Built Total Reason for S.No. Name of Vessel Type Or BHP Rank From To Manager Year MM/DD S/Off GRT

Support Expected Salary : ______Last Wages Drawn :______FPD 02 Rev No 1 Date: 01 Jan 2013 Page 3 of 4 REFERENCES Name of company Name of person to contact Address :

 No.

DECLARATION I hereby affirm that all this 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. I also certify that my medical history contained above is True and any false statement or undisclosed material information about past illness or injury will disqualify me from any employment benefits and claims.

Date______Rank__ Signature of Seaman ______This Is Computer Generated CV, Doesn’t Require Signature

FPD 02 Rev No 1 Date: 01 Jan 2013 Page 4 of 4