AFFIX HERE YOUR RECENT PASSPORT SIZE PHOTOGRAPH



[pic] | NORTRANSSM

OCS Services (India) Pvt.ltd

Tel:91-22-26744447/48/49/50

Fax:91-22-26743300

E-mail:operations@nortrans.co.in

RPSL-MUM-038

APPLICATION FORM

Form no: 501 rev: 06 Date : 01 - 06 - 09

|AFFIX HERE YOUR RECENT PASSPORT SIZE PHOTOGRAPH | |

|Post applied for : |Willing to accept lower rank? Yes / |Available From: / / |

1. Personal Details

|First Name: |Middle Name : |Last Name / Surname : |

|Nationality: |Date of Birth: |Place Of Birth: |

|Permanent Address |Present / Temporary Address Until |

| | |

|City Pin |City Pin |

|Tel: |Mobile: |Tel: |Mobile: |

|E mail: |E mail: |

|Nearest Airport : Mumbai / New Delhi / Chennai / Kolkata | |

|Document |Country |No. |Issued |Place |Valid Until |

|Passport | | | | | |

|Seamen’s Book |Indian | | | | |

|Seamen’s Book |Liberian | | | | |

|Seamen’s Book |Marshall islands | | | | |

|Seamen’s Book |Panamanian | | | | |

|Seamen’s Book |Other: | | | | |

|US visa – “C1” / “D” | | | | |

|Yes/No | | | | |

| |INDoS No. |ECNR : Yes /No . |

|Name of Nominee |Relation: |

|In case of fatality : | |

|Address SAME AS ABOVE |

|City Pin : |

|Tel: |

Family Details

|Relationship |First Name |Last Name |Date of Birth |Passport No. |Issued |Place |Valid Until |

|Wife | | | | | | | |

|Child M/F | | | | | | | |

|Child M/F | | | | | | | |

|Child M/F | | | | | | | |

|Child M/F | | | | | | | |

| | | | | | | | |

|Indicate the type of valid visa* USA C1/D CANADA BRAZIL UK |

|OTHERS |

|Height ( In cms ) |Weight (In Kgs) |Shoe Size : |Boiler Suit Size : |

2. Certificates / Courses

|A. Academic Qualification |Year of Passing |Highest Qualification attained |Class |

|School / College | | | |

| | | | |

| | | | |

|B. Training / Apprenticeship |From |To |Institution / University |

| | | | |

| | | | |

C.Highest Competency Certificate Held

|Issuing Authority : |Grade |Certification No. |Date Issued |Place Issued |Valid Until |

|National (Country) | | | | | |

|Liberian | | | | | |

|Panamanian | | | | | |

|Marshall Island | | | | | |

|Cayman Island | | | | | |

|Hong Kong | | | | | |

|Cyprus | | | | | |

D. Dangerous Cargo Certification

|1. Endorsement on NATIONAL Certificate |Number |Level |Date Issued |Place Issued |Valid Until |

|Petroleum | | | | | |

|Liquid Chemicals | | | | | |

E. Dangerous Cargo Endorsement ( Issued by Countries other than in Section 2D)

|Country |Type @ |Capacity # |Certificate No. |Date Issued |Valid Until |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

(#) Use following nomenclature: “Tankerman person in charge”, “ Tankerman assistant” @- Petroleum / Chemical

F. Watch Keeping Certificate: (For Ratings Only) (Include Liberian Special Qualification) :

|Certificate to work as ( e .g. AB/ Oiler) |Certificate No. |Date Issued |Place Issued |Valid Until |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

G. Courses Attended and Certificates Obtained

|Course / Certificates |Certificate Number |Date Issued |Institution / Place Issued |Valid Until |

|Fire Fighting ( Advanced/Basic) | | | | |

|Medical First Aid / Elementary First Aid | | | | |

|Proficiency in Survival Craft (PSCRB) | | | | |

|Personal Survival Techniques | | | | |

|Personal Safety & Social Responsibility | | | | |

|Specialized Training Prog. (Petroleum) | | | | |

|Specialized Training Prog. (Chemical) | | | | |

|Oil Tanker Familiarization | | | | |

|Ship Security Officer/ ( S.S.O.C.O.P) | | | | |

|Radar Observer | | | | |

|ARPA / RANSCO | | | | |

|Electro Tech. Officer (ETO) | | | | |

|Engine Simulator (Oper / Mang level ) | | | | |

|Ship Handling Simulator/LVHS | | | | |

|Liquid Cargo Handling Simulator | | | | |

|GMDSS Endorsement | | | | |

|GMDSS GOC | | | | |

|AMOS-D/P.M. S | | | | |

|BTM-Collision Avoidance | | | | |

|BERM/ ERM | | | | |

|Ship Safety Officer | | | | |

|Risk Management | | | | |

|ECDIS | | | | |

|Hydraulics & Pneumatics | | | | |

|PMEW/BEFT | | | | |

|Automation | | | | |

|Automation-PLC | | | | |

|Crew Safety | | | | |

|Tanker Vetting | | | | |

|ISM-Awareness | | | | |

|ISPS-Awareness | | | | |

|Yellow Fever | | | | |

|Others: | | | | |

| | | | | |

| | | | | |

3. General:

A. Have you ever been denied a foreign Visa? / No.

If yes, state which Country and reason ( If known ) :

B. Have you been the subject to court of enquiry or involved in a maritime accident ? / No.

If yes, pl attach the details

C. Do you have any Medical History/ Undergone surgery? / No

If yes, please attach details

D. References: (Please give references from 2 recent employers who we may contact for references.)

|Name of Company | | |

|Name of Person to Contact | | |

|Telephone | | |

For Office Use Only

|Company |Vessel / |Type* |DWT /GRT |Main Engine Type( Only |BHP |

| | | | |Engineers) | |

|TNC – Tanker(Crude) |TNP – Tanker(Product) |TNV – VLCC/ULCC |GAS – LPG/LNG Carriers |RF – Reefer |CH – Chemical Tanker |

|PAS – Passenger Ships |R/R – Ro-Ro Vessels |OSV – Offshore Vessels |PCC – Car Carriers |FSO/FPSO |OT – Others |

I hereby declare that all information furnished above is true to the best of my knowledge and belief. I further declare that prior joining your Company; I will stand released from my previous employment.

Date: Place: Signature of Applicant

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download