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APPLICATION FORM

1
Position
Position applied for:
Are you willing to accept any other positions?
If YES, which positions would you consider?
Readiness From

2
Personal details
Name:	Last Name(as per passport)	First Name(as per passport)
Date/place of birth:	Nationality:
Height in cms.	Weight in Kgs	Color of eyes
Color of Hair	Boiler suit size	Shoe size
Food Habit
Permanent Address:
Post code:	( No.:	(91) (Area Code) (Number)
( Mobile No.:	(91) ( ) (Number)	E-Mail Id:
3
Education Background
Name	From Year	To Year	Highest Qualification Attained
School
College
Pre Sea Training
Other Qualifications

4
Identity documents
DOCUMENT	COUNTRY	NUMBER	ISSUED	PLACE	EXPIRY(dd/mm/yyyy)
Passport:	INDIAN
Seaman’s book:	National
Bahamian
Liberian
Panamanian
Other -Norway
Indos Number	Yellow fever	LOT NO.	Date of Expiry	DD/MM/YYYY
Do you hold a US Visa ‘C1’?

Date of Issue	Date of expiry	DD/MM/YYYY
Do you hold a US Visa ‘D’?

Date of Issue	Date of expiry	DD/MM/YYYY
Have you been rejected for any visa applied for?
If YES, please state the country and reasons

5
Family details
Next Of Kin Relationship

Name:	Last Name(as per passport)

First Name(as per passport)

Address:
Post code:
Contact telephone numbers:	1st.	(91) (Area Code) (Number)	2nd	(91) (Area Code) (Number)
Marital Status:	Date of Birth of Spouse DD/MM/YYYY	Marriage Date : DD/MM/YYYY
Names of Children	Sex	Date of Birth( DD/MM/YYYY)

6
National Certificate of Competency (Highest certificate of competency held)
Class/Grade	Issuing Country	Certificate No.	Date Issued	Place Issued	Valid Until
DD/MM/YYYY	DD/MM/YYYY
DD/MM/YYYY	DD/MM/YYYY
GMDSS	DD/MM/YYYY	DD/MM/YYYY
GMDSS ENDRS.	DD/MM/YYYY	DD/MM/YYYY

6a
National Dangerous Cargo Endorsements
Endorsement Type	Certificate No.	Date Issued	Place Issued	Valid Until
Petroleum
DD/MM/YYYY	DD/MM/YYYY
Liquefied Gas
DD/MM/YYYY	DD/MM/YYYY
Chemicals
DD/MM/YYYY	DD/MM/YYYY

7
Flag State Equivalent Certificates Of Competency issued by other countries (Issued by countries other than in Section 6)
Class	Issuing Country	Certificate No.	Date Issued	Place Issued	Valid Until
Liberia	DD/MM/YYYY	DD/MM/YYYY
Panama	DD/MM/YYYY	DD/MM/YYYY
Bahamas	DD/MM/YYYY	DD/MM/YYYY
DD/MM/YYYY	DD/MM/YYYY

7a
Flag State Equivalent Dangerous Cargo Endorsements (Issued by countries other than in Section 6a)
Country/Type	Certificate No.	Date Issued	Place Issued	Valid Until
DD/MM/YYYY	DD/MM/YYYY
DD/MM/YYYY	DD/MM/YYYY
DD/MM/YYYY	DD/MM/YYYY

8
Certificates ( STCW and Value added)
CN Code	Course	Institution	Place	Date	Cert. No.
158	Personal Survival Techniques	DD/MM/YYYY
157	Basic Fire Fighting	DD/MM/YYYY
160	Elementary First Aid	DD/MM/YYYY
PSSR	Human Relations – PSSR	DD/MM/YYYY
140	Watch Keeping Certificate Deck / Eng	DD/MM/YYYY
151	Proficiency In Survival Craft - PSCRB	DD/MM/YYYY
160	Medical First Aid	DD/MM/YYYY
156	Advance Fire Fighting	DD/MM/YYYY
164	Ship Master’s Medical Care	DD/MM/YYYY
149	Radar Observer	DD/MM/YYYY
150	Radar Simulator	DD/MM/YYYY
161	ARPA	DD/MM/YYYY
166	Oil Tanker Familiarization	DD/MM/YYYY
168	Chemical Tanker Familiarization	DD/MM/YYYY
169	Gas Tanker Familiarization	DD/MM/YYYY
153	Adv. Oil Tanker Course	DD/MM/YYYY
154	Adv. Chemical Tanker Course	DD/MM/YYYY
155	Adv. LPG Tanker Course	DD/MM/YYYY
BTM	Bridge Team Management	DD/MM/YYYY
BERM	BRM / VRM / BERM / ERM	DD/MM/YYYY
SMSC	Ship Manoeuvre Simulator	DD/MM/YYYY
LCHS	Liq. Cargo Handling Simulator	DD/MM/YYYY
SSO	Ship Security Officer	DD/MM/YYYY
6GWC	6 G Welding For Fitter	DD/MM/YYYY
6GWF	6G Welding for Fitter with Class Cert.	DD/MM/YYYY
EDIS	ECDIS	DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY

9

9
Record of previous service
(Please give a full record starting with the last vessel on which you served)

VESSEL NAME	COMPANY#	VESSEL TYPE

FLAG	D.W.T.	G.R.T.	MAIN ENGINE##	B.H.P.	RANK	SIGN ON DATE

DD/MM/YYYY	SIGN OFF DATE	SEATIME
Make	Type
DD/MM/YYYY	Y-M-D
# Please ensure that the full name and address of your immediate past employer is entered in section 11	## Required for engineer applicants only

10
Medical history
Have you ever signed off a ship due to medical reasons?

Have you undergone any operation in the past?

Have you consulted a doctor during the last 12 months for an illness/accident?

Do you have any health or disability problems now?

(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)

11
General
Have you ever been the subject of a court of enquiry or involved in a maritime accident?
Have you ever had a professional licence suspended or revoked?
Do you have any Criminal record or have any investigation is going on

(If YES, please give full details and attach a separate page if necessary)

12
References (Please give the name and address of your current or immediate past employer)
Name of company
Name of person to contact
Address
Post Code:
( No.	(91) (Area Code) (Number)	(91) (Area Code) (Number)

12a
References (Please list two contactable referees or past employers in addition to Section 11)
Name of company
Name of person to contact
Address
Post Code:
( No.	(91) (Area Code) (Number)	(91) (Area Code) (Number)

13
Automatic review
If immediate employment is not available do you wish to be considered for future vacancies?
If YES, please give any alternative contact details not shown in Section 2

14
Declaration
I hereby declare that the above particulars are true and authorise you to contact the referees listed above.

Date:	( dd/mm/yyyy)
Name/Signature

1

BSMI/OP/103 Rev 3 Dated 12/FEB/2008

Hemant Sukalikar

2007-07-25

BARBER SHIP MANAGEMENT