APPLICATION FORM / PERSONAL DATA UPDATE FORM FOR OFFICER

APPLIED TO OFFICE IN CITY / COUNTRY :

PRESENT RANK

DATE OF APPLICATION

RANK APPLIED

DATE OF AVAILABILITY

1. PERSONAL DETAILS

NAME

Date of Birth

Place of Birth

 Nationality

Permanent Address

Present Address: 

City & Pin Code  : 

City & Pin Code   : 

Telephone           :

Telephone           : 

E-mail 1               :

E-mail 2               :  

Nearest Domestic Airport :

Nearest International Airport::

3. PASSPORT DETAILS

 

      NUMBER

PLACE OF ISSUE

DATE OF ISSUE

DATE OF EXPIRY

PASSPORT

US VISA (B1/B2)

ECNR

4. CONTINUOUS DISCHARGE CERTIFICATE (S)

CDC

      NUMBER

PLACE OF ISSUE

DATE OF ISSUE

DATE OF EXPIRY

INDIAN

LIBERIAN

PANAMA

OTHERS

5. ACADEMIC QUALIFICATIONS

 

 

Grade/Degree         

From (Year)      

To (Year)

SCHOOL

COLLEGE

PRESEA TRAINING

6. PERSONAL DETAILS

Height Weight
Color of eyes Color of Hair

Any major illness / Surgery : NO (If “YES”, Kindly provide details separately)

7. HOW DID YOU COME TO KNOW ABOUT US? (Please tick the appropriate medium) √

A

Company presentation/seminar

B

Marine Club notice-board

C

Marine magazine advertisement

D

Newspaper advertisement

E

Told by seagoing friend (s)

F

Direct Mail from Company

G

Others (Please specify)

 

 

 

 

 

 

8. STCW AND OTHER CERTIFICATES

STCW Courses

Certificate No

Date of Issue

Date of Expiry

Place of Issue

Issuing  Authority/
INSTITUTE

PSSR

EFA

PST

FP & FF / AFF (Fire Fighting)

GMDSS

REFRESHER & UPDATING

INDOS NO.

WATCHKEEPING CERTIFICATE FOR RATINGS

TANKER COURSES

TASCO / TANK FAM

CHEMCO / CHEM FAM

GASCO / GAS FAM

DCE PETROLEUM

DCE CHEMICAL

DCE GAS

OTHER COURSES

 ISPS (SOC)

HUET

H2S

COOKERY COURSE

WELDING 2G,3G,6G

9. REFERENCES (Please give two references/companies whom we can ask about your seagoing experience)

Name

Company/Designation

Telephone/Contact NO.

1

2

11. SEA EXPERIENCE: (Most recent at Top)
Special Experience:

COMPANY

NAME

TYPE

DWT

GRT

RANK

MODEL

BHP

FROM

TO

 

I declare that the information given by me in filling up this form to the best of my knowledge are true complete. I also declare that the documents submitted to NAUTICAL MARINE MANAGEMENT SERVICES PVT. LTD. Are genuine, given and signed by the persons whose names appear on them. Any false declaration may render me liable for termination or dismissal

Date :