APPLICATION FORM / PERSONAL DATA UPDATE FORM
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RANK APPLIED |
2nd OFFICER |
DATE OF APPLICATION |
20.02.2019 |
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INDOS NUMBER |
06NL1224 |
DATE OF AVAILABILITY |
20.02.2019 |
1. PERSONAL DETAILS SURNAME FIRST NAME MIDDLE NAME
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NAME
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MEENA |
RAM |
KUMAR |
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Date of Birth |
07.05.1986 |
Place of Birth |
JAIPUR |
Nationality |
INDIAN |
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Permanent Address |
VILL-DAULATPURA,POST-DHARAMPURA,VIA BANSKHO(BASSI),DIST-JAIPUR(RAJ) |
Present Address |
6 MB/313,INDIRA GANDHI NAGAR, JAGATPURA , JAIPUR,RAJASTHAN |
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City & Pin Code : 303305 |
City & Pin Code : 302017 |
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Telephone : 9001860565/9653492351 |
Telephone : 9001860565/9653492351 |
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E- mail 1 : meenaramkumar208@gmail.com |
E- mail : meenaramkumar208@gmail.com |
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2. NEXT OF KIN / FAMILY PARTICULARS
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NAME / RELATION |
SH. NATHU LAL MEENA/ FATHER |
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ADDRESS |
VILL-DAULATPURA,POST-DHARAMPURA,VIA-BANSKHO(BASSI),DIST.-JAIPUR, RAJASTHAN |
3. PASSPORT DETAILS
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|
NUMBER |
PLACE OF ISSUE |
DATE OF ISSUE |
DATE OF EXPIRY |
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PASSPORT |
R2840743 |
JAIPUR |
17.07.2017 |
16.07.2027 |
4. CONTINUOUS DISCHARGE CERTIFICATES
|
CDC |
NUMBER |
PLACE OF ISSUE |
DATE OF ISSUE |
DATE OF EXPIRY |
|
INDIAN |
MUM147123 |
MUMBAI |
19.03.2018 |
18.03.2028 |
5. ACADEMIC QUALIFICATIONS Grade / Degree From (Year) To (Year)
|
COLLEGE |
T S CHANAKYA |
BSC NAUTICAL SCIENCE |
AUG -2005 |
AUG-2008 |
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PRE- SEA TRAINING INSTITUTE |
T S CHANAKYA |
BSC NAUTICAL SCIENCE |
AUG-2005 |
AUG-2008 |
6. LICENCE / CERTIFICATE OF COMPETENCY
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|
Grade |
Number |
Date of Issue |
Date of Expiry |
Date of Revalidation |
STCW 95 YES NO |
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INDIAN |
CHIEF MATE FG |
IFO-22016 |
09.03.2018 |
31.01.2023 |
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7. STCW AND OTHER CERTIFICATES
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STCW Courses |
Certificate No. |
Date of Issue |
Date of Expiry |
Place of Issue |
Issuing Authority/ INSTITUTE |
|
PSSR |
PSSR/169/2007 |
09.04.2008 |
NAVI MUMBAI |
T S CHANAKYA |
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EFA/MFA/MEDICARE (First Aid) |
EFA/200/2007 |
09.04.2008 |
NAVI MUMBAI |
T S CHANAKYA |
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|
PST/ PSCRB (Survival) |
BPMA/PSCRB/294/2010 |
19.02.2010 |
NAVI MUMBAI |
BP MARINE |
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FP & FF / AFF (First Fighting) |
4756 |
13.02.2010 |
NAVI MUMBAI |
T S CHANAKYA |
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ROC |
RO10103 |
14.05.2010 |
DELHI |
ARI |
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ARPA |
AR10111 |
21.05.2010 |
DELHI |
ARI |
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GMDSS |
M-2891 |
23.04.2010 |
22.04.2020 |
MUMBAI |
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GMDSS END |
M/GOC/12/2549 |
24.08.2015 |
22.04.2020 |
MUMBAI |
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REFRESHER & UPDATING |
NATCOM/UP/244/2015 |
21.08.2015 |
DELHI |
NATCOM |
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RANSCO / NARAS |
NATCOM/RANSCO/050/2017 |
18.05.2017 |
DELHI |
NATCOM |
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S0MS/ NAV CONTROL |
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W/K CERT. FOR RATINGS |
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SIMULATOR TRAINING |
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ENGINE SIMULATOR |
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BTM |
BTM/1407/2010 |
01.12.2010 |
MUMBAI |
OERC |
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ECDIS |
YAK/ECDIS/015/10/13/02 |
18.10.2013 |
MUMBAI |
YAK |
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ICE NAVIGATION |
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BRM/ ERM / VRM |
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TANKER COURSES |
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TASCO / TANKER FAM. |
STO/09/12/193 |
14.09.2012 |
NAVI MUMBAI |
MASSA |
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CHEMCO/ CHEM FAM. |
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GASCO/ GAS FAM. |
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DCE PETROLEUM |
M/O/1/N/13/25563 |
29.08.2016 |
28.08.2021 |
MUMBAI |
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DCE CHEMICAL |
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DCE GAS |
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LIQUID CARGO SIM |
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OTHER COURSES |
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Safety Officers Cert/ ISPS ( SOC) |
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HAZMAT |
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SSO |
MMC/SSO/2015/048 |
24.07.2015 |
MUMBAI |
MMC MUMBAI |
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COOKERY COURSE |
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WELDING 2G,3G,6G |
8. SEA EXPERIENCE: (Most recent first)
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COMPANY |
VESSEL |
MAIN ENGINE |
PERIOD |
REASON FOR SIGN- OFF |
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NAME |
TYPE |
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GRT |
YEAR BUILT |
RANK |
MAKE |
|
BHP |
|
FROM |
TO |
M/D |
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|
MERCATOR LIMITED |
M.T. PREM MALA |
PRODUCT TANKER |
|
28522 |
2000 |
2/OFF |
B&W |
|
10480 |
|
10.05.2018 |
16.10.2018 |
05/07 |
COC |
|
MERCATOR LIMITED |
M.T. HARSHA PREM |
PRODUCT TANKER |
|
25644 |
1995 |
2/OFF |
B&W |
|
12750 |
|
21.09.2016 |
06.03.2017 |
05/15 |
COC |
|
MERCATOR LIMITED |
M.T. HARSHA PREM |
PRODUCT TANKER |
|
25644 |
1995 |
2/OFF |
B&W |
|
12750 |
|
22.09.2015 |
25.03.2016 |
06/03 |
COC |
|
MARINE SOLUTIONS |
GAGASAN KEDAH |
PRODUCT TANKER |
|
5511 |
2011 |
2/OFF |
MAN RESITA |
|
3310 |
|
22.08.2014 |
28.02.2015 |
06/06 |
COC |
|
TRANS OCEAN PVT LTD |
MT F1 |
PRODUCT TANKER |
|
11194 |
1995 |
2/OFF |
B&W |
|
6030 |
|
05.11.2013 |
30.04.2014 |
05/25 |
COC |
|
SCI |
MV MAHARASHTRA |
BULK CARRIER |
|
28029 |
1995 |
2/OFF |
B&W |
|
9020 |
|
02.10.2012 |
07.02.2013 |
04/05 |
COC |
|
SCI |
M.T. GURU GOBIND SINGH |
OIL TANKER |
|
80130 |
1995 |
2/OFF |
B&W |
|
19100 |
|
21.09.2011 |
08.05.2012 |
07/17 |
COC |
|
SCI |
MV DAKSHINESHWAR |
BULK CARRIER |
|
28739 |
1986 |
3/OFF |
B&W |
|
10800 |
|
05.01.2011 |
05.08.2011 |
07/00 |
COC |
REASON FOR SIGN OFF- COC
9. REFERENCES (Please give two references/companies whom we can ask about your seagoing experience)
|
Name |
Company/ Designation |
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CAPT. M.S.WADHWA |
MERCATOR LIMITED |
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CAPT. PANKAJ KUMAR |
SCI |
10. DECLARATION
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I assure that the information given by me in filling up this from to the best of my knowledge are true and complete. I also assure that the documents submitted to are genuine, given and signed by the persons whose names appear on them. Any false declaration may render me liable for termination or dismissal
Date: SIGNATURE OF APPLICANT:
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