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CENMAR

MARITIME AGENCIES (INDIA) PVT LTD

64 A, Mittal Court Bldg., Nariman Point, Mumbai 400 021

Tel : +91-22-2202 2278/79 Fax : +91-22-2202 2250

APPLICATION / PERSONAL DATA FORM

Month Available for Service: Date Applied:

[IMPORTANT : PRINT ALL ENTRIES USING BLACK BALL PEN & IN CAPITAL LETTERS]

[Family Name] [Given Name] [Middle Name]

Post Applied For : Alternate Rank :

Contact Address :

Tel. No:

Permanent Address :

Tel. No:

Date of Birth (Dy/Mo/Yr ) : Place of Birth : Age :

Religion : Marital Status :

Height : Weight : Shoe Size : Coverall Size :

EDUCATIONAL ATTAINMENT

Grade / Level Name of Schools Attended Year Completed

From To

(Dy/Mo/Yr) (Dy/Mo/Yr)

Elementary :

High School :

College :

Highest Educational Attainment (DEGREE)

CREDENTIALS RECORD

(Dy/Mo/Yr)

National License No. Date Issued Grade:

STCW’95 Endorsement Reg. No. Date Issued Expiry Date :

Flag Endorsement No. Date Issued Rank:

Seaman’s Book No. Date Issued Expiry Date : Place Issued

Other Seaman’s No. Date Issued Expiry Date : Place Issued

Passport No. Date Issued Expiry Date : Place Issued

US Visa (if any) No. Date Issued Place Issued :

Immigration Clearance Reqd. Yes / No

INDOS No. Date Issued Expiry Date : Place Issued

Deck/Engine Watch keeping Cert. No. Date Issued Training Center :

Yellow Fever No. Date Issued Place Issued :

CERTIFICATES HELD
ITEM	No.	ISSUED	EXPIRING	ISSUED BY
Revalidated Training Cert.
Personal Safety & Social Responsibilities (PSSR)
Personal Survival (PST)
Proficiency in Survival Craft / Rescue Boat (PSC/RB)
Fire Fighting and Fire Prevention (FFFP) / Shore Based F.F.
Advanced Fire Fighting
Petroleum Tanker Safety / Basic Oil Tanker Familiarisation
Petroleum Tanker Safety-Advanced / Specialised Training in Oil Tanker
COW / IGS
Dangerous Cargo Endorsement
Liquid Cargo Handling Simulator [LCHS]
Ship’s Captain’s Medicare / Medical First Aids (MFA)/ Elementary First Aid Course (EFA)
Radar Observer’s Course R.O.C.
ARPA
Radar Simulator’s / Radar and Navigation simulator course (RANSCO)
International Safety Management Course (ISM)
GMDSS / GOC
STCW Endorsement [GOC]
Bridge / Engine Resource Management
S.M. Simulator & Bridge Team Management
Engine Room Simulator
Operational Use of Electronic Chart Display & INFO, SYS (EC DIS)
Ship Security Officer Course / ISPS Familiarisation
Marpol I / Marpol II

SEAGOING EXPERIENCE [ Starting from the last Vessel]
MANNING AGENCY / SHIPPING COMPANY	VESSEL NAME			ENGINE		RANK	SIGN – ON Dy/Mo/Yr	SIGN – OFF Dy/Mo/Yr	TOTAL SERVICE		SIGN – OFF REASON
	NAME	DWT	TYPE	TYPE	BHP				Mo	Dy

NUMBER OF DEPENDENTS
Name	Date of Birth	Relation	Passport Number	Date of Issue	Expiry Date	Place of Issue
1.
2.
3.
4.
Father’s Name Mother’s Name

Pls. Attach Extra Sheet If Required Start From The Last Vessel Served On.

Who referred you to CENMAR ?

Any relative in CENMAR ? If YES, who? If YES, who?

Trade route of past vessels (Last 3 years)

Are you willing to accept assignments in any part of the world?

If so, are you willing to obey all terms and conditions of employment?

Have you ever contacted any disease? If YES, what is the nature?

Person to notify in case of emergency:

NAME RELATION RELATION

ADDRESS TEL. NO. TEL NO.

Are you a member of ITF / Union Membership No.

Do you have any pending case with any other Shipping Agency?

If YES, state your case

I HEREBY CERTIFY AND CONFIRM that the foregoing information is true and correct and

that any misrepresentation or distortion of material facts will be sufficient round for denial of this

application. I’m aware that any falsification of the above shall be a cause of my dismissal in case I am

employed. I ALSO CERTIFY AND CONFIRM that I have not paid not promised to pay any monetary consideration.

__________________________

APPLICANTS SIGNATURE