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