BIO DATA AND APPLICATION OF VANKA SRINIVAS

1. Personal Data

First Name : SRINIVAS	Middle Name (s) : -		Last Name / Surname : VANKA
Nationality (or current Citizenship)	Country Of Origin	Date of Birth	Place / City of Birth
INDIAN	INDIA	29.03.1955	INDIA / CALCUTTA
Marital Status	Gender:
MARRIED	Male      ☑ Female  ☐

2. Personal ID / Documents / Visa

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3. Nominee / Next of Kin & Family Details

Select From:         ♦ Spouse                    ♦ Partner                    ♦ Grand Parent                 ♦ Other Relative (Please Specify)

Family data:

Indicate type of valid visa³                                                    ☑        USA                      ☐         Canada                    ☐        Brazil              ☐        Schengen             ☐     UK                  ☐ Other

²Strike out inapplicable item                                                   ³Please consider period board

4.  STCW-1978 (ammended 1995) Compliant Certificates / Courses and Other Qualifications:-

Add separate sheet if data exceeds space available)

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5. Sea Experience: (Last 10 years; Start the listing below with the most recent experience)

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6. Medical History:

All previous illnesses other than minor afflictions should be started below or updated . If not previously disclosed, the Company is

entitled to refuse any reimbursement of medical coasts, claim for treatment or for any other insured benefits.

(A)    Have you ever signed off a ship due to medical reasons?                                                                                                                                                                                                                    Blood Type:

                  If yes, please provide following details (if space is insufficient, attach additional sheets):                                                     Yes               ☐                                   No        ☑                                 O +VE

(B)    Have you undergone any operation in the past?                                                                                                                                        Yes             ☑                                              No            ☐                                                                                If yes, please provide following details:

(C)    For what illnesses or accidents have you consulted a doctor during the last 12 months?     

(D)     Please give details of any health or disability problem

7.   General

(A)     Have you ever been denied foreign visa?                                                                         Yes      ☐                                                       No    ☑

             If yes, state which country and reason (if know)          ………………………………………………...

(B)     Have you been the subject of a court of enquiry or involved in a maritime accident?                Yes       ☐                                                   No     ☑

             If yes, please attach details

(C)     Give details below of two recent employers who we may contact for references:

I hereby accept that the above, Including Medical History, is true.I further consent to the holding and processing by you and any of your direct or indirect parent or subsidiary or 

associated or affiliated companies ("MSI") and your or MSI principals of personal data about me (including where appropriate data concerning racial or ethnic origin, religious

beliefs, membership of a trade union, physical or mental health or condition, commission or alleged commission of an offence and the proceedings and this outcome of any 

proceedings relating thereto) for all purposes related to my application for employment on board vessels managed by MSI, owned or operated by third parties for whom MSI

is engaged to provide crew. I understand that this data will be stored in your databases in relation to my actual or potential employment by or through MSI. Further, I confirm that

the above may involve the transfer or my personal data within MSI or to third parties worldwide.

Place:-          CHENNAI                                                                           Date:-  7- Aug-19                                                                   Signature:-      

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