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
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