APPLICATION FORM

1

Position chief engineer ID/PD No. (For Office Use Only) _______________________

Position applied for:

Are you willing to accept any other positions? If YES, which positions would you consider?

NO

Are you responding to a media advertisement? If YES, please state which publication

NO

From what date will you be available? ( Ready to join Any Time)

2

Personal details

Name:

(Surname) NADUKKUDY

(First Names) MOIHEEN

(Middle Name) ALIAR

Date/Place of Birth:

15/02/1960

Nationality:

INDIAN

Permanent address:

NADUKKUDYIL HOUSE,PAIMATTOM,PAREKKANNY.P.O, E K M (Dist.) KERALA(State)

INDIA.

Pin Code: -686693

E-Mail:

nadukkudy@gmail.com

Tel No:-Mobile:-9987765179

Mobile

9820487716

Local address:

403-SWATI, AKASH GANGA COMPLEX,VIJAY GARDEN, GAUD BUNDER ROAD,

THANE (WEST), MAHARASRA (STATE) INDIA.

Pin Code: 400615

E-Mail:

nadukkudy@ymail.com

Tel No.04722802023/8655050151

Mobile

9496195812

3a

Educational Background

Qualification

School / College

From

To

Percentage/ Grade

S S L C

ST JOHNS H S

1974

1975

70 / First class

PRE DEGRE

MAR AHENESIOUS COLLEGE

1976

1978

83 / First class

3b

Technical Background

Degree/ Diploma

Institute/ College

From

To

Percentage / Grade

B E MECHANICAL

MAR AHENESIOUS COLLEGE

1979

1984

72/ First class

M B A

I I B M INSITUE OF BISNESS MGT

2013

2014

A PLUS

4

Identity documents

DOCUMENT

COUNTRY

NUMBER

DATE OF ISSUE

PLACE OF ISSUE

DATE OF EXPIRY

Passport:

INDIAN

J 9456157

17/01/12

COCHIN

16/01/22

Seaman Book:

National

MUM 105155

30/05/12

MUMBAI

29/05/22

PANAMA C D C

Panama

200248589

24/11/16

PANAMA

15/11/21

Liberian

Honduras C D C

HONDURAS

T I R-51-RH -21326

03/06/15

HONDURAS

03/06/20

Do you hold a US Visa ‘C1/D’?

YES

Issue Date:

21/11/08

Expiry Date: 18/11/13

Do you hold a US Visa ‘B1/B2’?

NO

Issue Date

Expiry Date:

Have you been rejected for any visa applied for?

NO

If YES, please state the country and reasons

INDOS No: (only for Indian) 0IEL 1632

YELLOW FEWER - LOT NO : 039-Exp Date-12/01/2022

MUI NO : E 043130

5

Family Details: (If Unmarried kindly give details of Father / Mother)

NAME

Relation

DOB

POB

PASSPORT NO.

PLACE OF ISSUE

DATE OF ISSUE

DATE OF EXPIRY

ECNR

DR SHAFNU R.S.

WIFE

22/09/72

6

Certificates (Highest certificate of competency held) CHIEF ENGINEER

Grade/Class Of COC Country

Issuing Country

Date of Passing Exam

Certificate No.

Date Issued

Place Issued

Valid Until

CHIEF -ENG

PANAMA

29/10/16

CT040550/16

24/11/16

PANAMA

15/11/21

CH ENG

HONDURAS

14/08/09

MN-1942-M-

03/06/15

HONDURAS

03/06/20

7

Certificates Of Competency issued by other countries (Issued by countries other than in Section 6)

Issuing Country

Certificate No.

Date Issued

Place Issued

Valid Until

HONDURAS

MN-1942-M

14/08/09

HONDURAS

03/06/20

8

Details of Courses

ALL Courses UP Dated -2010

Certificate No.

Issued By

Date Issued

Date Of Expiry

FPFF / AFF

REF/AFF-98-14/001053

URO TEC

07/07/14

06/07/19

MEDICARE

REF/MFA-43-14/000554

URO TEC

18/07/14

17/07/19

PSCRB

REF/PSCRB-99-14001179

URO TEC

08/07/14

07/07/19

PST

REF/PST-152-14/001852

URO TEC

08/07/14

07/07/19

PSSR – Personal Safety & Social Responsibilities

PSSR/EMA-926-14/015436

URO TEC

10/07/14

UNLIMITED

SSO – Ship Security Officers Course

REF/SSO-1/19-14/001348-

URO TEC

18/07/14

UNLIMITED

S S O LICENCE PANAMA (ENDORDEMENT)

SSO- 00143288

PANAMA

16/11/16

07/10/21

S S O LICENCE-HONDURAS (ENDORSEMENT)

MN-1026

HONDURAS

03/06/15

03/06/20

MEDICAL FIRST AID

MFA-006/01/APR/16

SEVEN SEAS

06/04/16

05/04/16

Chief engineer updated course( FROM SHIP RAHMAN)

PEC-055-2009

Ship Rah Rahman

14/08/09

UN LIMITED

ELEMENTRY FIRST AID

EFA-0011/01FEB/16

SEVEN SEAS

26/02/16

UNLIMITED

Chief engineer updated course (Panama)

CC/14-01-076

Prof Mariti

25/11/14

UNLIMITED

TANKER ENDORSEMENT

Oil Tanker endorsement(TASCO) MGT LEVEL

CTB 230690

Panama

30/07/2014

29/04/2019

Chemical Tanker Endorsement(CMEMCO) MGT LEVEL

CTB 230690

Panama

27/01/2014

16/01/2019

Gas Tanker Endorsement (GASCO) MGT LEVEL

CTB 230690

Panama

08/01/2014

19/12/2018

TANKER COURSES

Tanker safety (TASCO)

EMA/47-10/373

UroTech

30/04/2010

Un limited

Chemical Tanker Safety (CMEMCO)

SCTO/2371/2009

O E R C

14/05/2009

Un limited

Gas Tanker Safety ( GASCO)

STPLGT/1100/2013-14

O E R C

19/12/2013

Un limited

Tanker vetting Inspection

Cert.No.201

UNIVAN

04/02/08

Unlimited

Instrumentation & Shipboard Control Systems

Automation and Controls

Container Refrigeration

Hydraulics for Engineers (Basic / Advance)

Hazmat (In compliance with STCW-95 Section-B -V/b & V/c & CFR – 49)

CFR-49

Hydraulics and Pneumatics Workshop

PROFICIENCY IN FAST RESCUE BOATS

0105/01/OCT/2016

SEVEN SEAS

05/10/16

04/10/16

Applied Electronics (AELC)

Practical Marine Electrical Workshop

Engine Equipment Maintenance Workshop

Basic Electrical and Fluid Technology

Reefer Container and Maintenance Course

ENGINE ROOME RESOURSE MGT

ERM-0113/02/SEP/16

SEVEN SEAS

21/09/16

2O/09/21

LEADER SHIP AND TEAM WORK

LSTW-0158/02/OCT/2016

SEVEN SEAS

14/10/16

13/10/21

MARINE ENVIRONMENTAL AWARENESS

MEA-0156/01/OCT/2016

SEVEN SEAS

29/10/16

28/10/21

ENGINE ROOM SIMULATOR

ERS-0061/01SEP/16

SEVEN SEAS

15/09/16

14/09/21

S T S D S D ( From B P Marine)

STS/3762/2014

B P Marine

14/11/2014

Unlimited

POLICE CLEARENCE CERTIFICATE

SB /VRFN/PVT JOB/

THANE

18/12/15

09000/2015

SPOFFICE

9

9

Record of previous service

(Please give a full record starting with the last vessel on which you served)

COMPANY

VESSEL NAME

VESSEL TYPE

GRT

CONTS TEU’S

VSL AGE

TYPE OF ENGINES

(Please give full dtls)

B.H.P

RANK

SIGN ON dd/mm/yy

SIGN OFF dd/mm/yy

DURATION yy/mm/dd

REASONS FOR S/OFF

Integrity ship mgt

M.T. Ark Pioneer

Che T

4526

25

Akasakh Mitsubhishi

4200

Chen

21/11/16

20/01/17

2 Months

Short contract

Integrity ship mgt

M.V. Yangtze

B/C

38678

16

Mitisui BMW

13238

Chen

08/04/16

03/09/16

4M 27Days

Contract comp

Integrity ship mgt

M.V.Feng

B/C

39464

32

Hitachi BMW

12500

Cheng

22/10/15

10/11/15

20 Days

Repair job