figure 03 - cv - sea staff application form
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Mideast: 025FLEET PERSONNEL ADMINISTRATION
PHOTO
APPLICATION FOR POSITION AS 3rd ENGINEER OTHER POSITION (IF ANY)
Figure 03, Revision 001, Dated 01.05.09
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SEA STAFF APPLICATION FORM
Mideast: 025FLEET PERSONNEL ADMINISTRATION
1. PERSONAL DETAILSTITLE MR/MRS/MISS MR SEX MALE FEMALE SURNAME NARE
FIRST NAME GAURAV OTHERS NAMES
DATE OF BIRTH 15 FEB 1985 PLACE OF BIRTH MUMBAI
NATIONALITY INDIAN MARITAL STATUS UNMARRIED
COLOUR OF EYES BLACK COLOUR OF HAIR BLACK
MOTHER’S NAME VARSHA NARE FATHER’S NAME VILAS NARE
MOTHER’S MAIDEN NAME
HEIGHT (CM) 173 WEIGHT (KG) 73
NEAREST INTERNATIONAL AIRPORT: MUMBAI
2. ADDRESS ADDRESS (TEMP.) FROM/TO:NO & STREET 18/803,SAFFRON,REGENCY
ESTATE,KALYAN SHIL ROADNO & STREET
CITY DOMBIVLI EAST CITYPOST CODE 421203 POST CODECOUNTRY INDIA COUNTRYTEL. NO. TEL. NO.MOBILE 7738821243/7506364819 MOBILEE-MAIL [email protected] E-MAILFAX FAX
3. NEXT OF KINFULL NAME VILAS GOVIND NARE RELATIONSHIP FATHER
ADDRESS 18/803,SAFFRON,REGENCY ESTATE,KALYAN SHIL ROAD,THANE DIST DOMBIVLI EAST
CITY DOMBIVLI COUNTRY INDIA
TEL. NO. MOBILE 9967764819 FAX NO.
4. CHILDRENFULL NAME OF CHILD DATE OF BIRTH SEX
M F M F M F M F
5. TRAVEL DOCUMENTSTYPE DOCUMENT NO. ISS.DATE EXP. DATE ISS. BY (AUTHORITY) PLACE OF ISSUE
PASSPORT G 2091699 21/02/2007 20/02/2017 INDIA THANE
SEAMAN BOOK MUM 148259 13/02/2009 12/02/2019 INDIA MUMBAI
OTHER SEAMAN BOOK MH 368136 01/08/2014 21/07/2019 MARSHALL ISLAND VIRGINIA,USA
US C1/D VISA H8817629 26/12/2013 23 /12/2018 USA MUMBAI
OTHER VISAS
6. BANK ACCOUNT INFORMATION BANK NAME AXIS BANK BRANCH DOMBIVLI EASTBANK ADDRESS
CITY DOMBIVLI COUNTRY INDIA
SORT CODE UTB0000125 ACCOUNT NO 060010100388054
Figure 03, Revision 001, Dated 01.05.09
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Mideast: 025FLEET PERSONNEL ADMINISTRATION
BANK SWIFT CODE BANK TEL. NO 0251-2800671
ACCOUNT OWNER’S NAME GAURAV VILAS NARE
ACCOUNT OWNER’S ADDRESS 18/803,SAFFRON,REGENCY ESTATE,KALYAN SHIL ROAD,DOMBIVLI EAST DIST.THANE
7. EDUCATION SCHOOL NAME
S.H.JONDHALE VIDYA MANDIRFROM 1989 TO 2001
SCHOOL NAME FROM TO
8. PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY
CERTIFICATE NAME NUMBER ISSUE DATE EXPIRY DATE
ISSUED BY (AUTHORITY) ISSUED AT
CL IV INDIA 95Z-12416 08/12/2010 06/02/2020 INDIA MUMBAI
DANGEROUS CARGO ENDORSEMENT NUMBER ISSUE DATE EXPIRY DATE
PETROLEUM M/0/2/E/12/19856 29/08/2012 31/12/2016
CHEMICAL M/C/1/E/13/23280 05/06/2013 31/12/2016
GAS
9. LANGUAGES ENGLISH FLUENT GOOD FAIR POOR
GERMAN FLUENT GOOD FAIR POOR
FRANCH FLUENT GOOD FAIR POOR
SPANISH FLUENT GOOD FAIR POOR
ITALIAN FLUENT GOOD FAIR POOR
RUSSIAN FLUENT GOOD FAIR POOR
MARLIN’S TEST / LEVEL ISSUED DATE RESULT % ISSUED BY (AUTHORITY) ISSUED AT
10. HEALTH CERTIFICATES & VACCINATIONS
FLAGE STATE NUMBER ISSUE DATE
EXPIRY DATE
ISSUED BY (AUTHORITY) ISSUED AT
INTERNATIONALLIBERIANNORWEGIANPANAMANIAN
NAME ISSUE DATE EXPIRY DATE ISSUED BY (AUTHORITY) ISSUED AT
YELLOW FEVER 5/12/2008 04/12/2018 INDIA MUMBAI
11. SAFETY CLOTHINGBOILERSUIT SIZE XL BOOTS SIZE 9
12. MARINE COURSESIFigure 03, Revision 001, Dated 01.05.09
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Mideast: 025FLEET PERSONNEL ADMINISTRATION
COURSE NAME NUMBER ISSUE DATE
EXPIRY DATE
ISSUED BY (AUTHORITY) ISSUED AT
PERSONAL SURVIVAL SGA/PST/2007-802-10537 22-12-2007 21-12-2012 SAGAR GYAN MUMBAI
BASIC FIRE FIGHTING FPFF/8006/2008 12-01-2008 11-01-2013 OERC ACADEMY MUMBAI
ADV. FIRE FIGHTING BPMA/AFF/RF/181/2015 27.01.2015 26.01.2020 BP MARINE MUMBAI
ELEMENTARY FIRST AID EFA/2825/2007 28.12.2007 27.12.2012 OERC ACADEMY MUMBAI
MEDICAL FIRST AID BPMA/ENGR-UP/28/2015 07.02.2015 BP MARINE MUMBAI
MEDICAL CARE
PERS. SAFETY & SOC. RESP. BPMA/ENGR-UP/28/2015 07.02.2015 BP MARINE MUMBAI
PROF. IN SURVIVAL CRAFT & RESCUE BOATS RPSCRB C/B44/03 31.01.2015 HIMT CHENNAI
FAST RESCUE CRAFT
G.M.D.S.S.
A.R.P.A. (Management level)
RADAR OBSERVATION
HAZMAT
OIL TANKER BPMA/TFC/829/2008 14.11.2008 BP MARINE MUMBAI
ADVANCE OIL TANKER BPMA/ATOT/453/2011 15.10.2011 BP MARINE MUMBAI
CHEMICAL TANKER BPMA/CTFC/894/2008 21.11.2008 BP MARINE MUMBAI
ADVANCE CHEM ANKER STC/02/13/032 29.03.2013 MASSA MUMBAI
GAS TANKER
ADVANCE GAS TANFC/KER
CRUDE OIL WASHING
INERT GAS PLANT
ISM CODE
SHIP SECURITY OFFICER
BRIDGE TEAM MANAGEMENT
DP INDUCTION
DP SIMULATOR
BRIDGE / ENGIINE ROOM RESOURCE MANAGEMENT.SHIP HANDLING
INTERNAL AUDITORS COURSE
STSCSD STS/55/13/1120 20.12.2013 MASSA MUMBAI
12. MARINE COURSES (CONTD……)
COURSE NAME NUMBER ISSUE DATE
EXPIRY DATE
ISSUED BY (AUTHORITY) ISSUED AT
13. SPECIALISED EXPERIENCETYPE FROM TO COMMENTS
Figure 03, Revision 001, Dated 01.05.09
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Mideast: 025FLEET PERSONNEL ADMINISTRATION
NEW BUILDING
SPECIALISED PROJECTS
SPECIAL TRADES
SHORE EXPERIENCE
Figure 03, Revision 001, Dated 01.05.09
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Mideast: 025FLEET PERSONNEL ADMINISTRATION
COMPLETE SEA – SERVICE DETAILS( LAST VESSELS FIRST )
NAME: GAURAV VILAS NARE RANK: 3/E
AVALIABILITY DATE:07 JULY 2015 ONWARDS
COMPANY NAME RANK VESSEL NAMESIGNED
ONSIGNED
OFF
PERIOD IN
MONTHS (eg 4.2)
TYPE OF VESSEL D.W.T.
ENGINE TYPE( ENGINEERS
ONLY)BHP KW
NAVIG8 SHIP MGMT 3/E M.T NAVIG8 FAITH 21.05.2014 23.11.2014 6.1 Product TankerMAN B&W 11610 8530
NAVIG8 SHIP MGMT 3/E M.T.ZHONGJI NO.2 18.03.2014 05.05.2014 1.7Oil Chem Tanker WARTSILLA 12730 9360
NAVIG8 SHIP MGMT 4/E M.T.ZHONGJI NO.1 20.06.2013 05.12.2013 5.5Oil Chem Tanker WARTSILLA 12730 9360
GENMARCO 4/E M.T. MORNING GLORY V 20.10.2011 01.04.2012 5.5 Oil TankerMAN B&W 13510 9930
SOVEREIGN SAFESHIP 4/E M.T.UNION PRIDE 28.01.2011 18.05.20113.7
Product TankerHANSHIN 4500 3300
FIVE STAR SHIPPING 5/E M.T.MAHA GAYATRI 24.03.2009 09.11.2009 7.6 Bulk carrier SULZER 11550 8490
REFERENCE CONTACT DETAILS COMPANY NAME NAVIG8 SHP MGMT
ADDRESS B-210,EVEREST GRANDE,ANDHERI EAST
PHONE NO. 022 6606 0000
FAX/E-MAIL [email protected]
CONTACT PERSON MR.AJIT KESARKODI
Figure 03, Revision 001, Dated 01.05.09
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Mideast: 025FLEET PERSONNEL ADMINISTRATION
DATE SIGNATURE
Figure 03, Revision 001, Dated 01.05.09
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Mideast: 025FLEET PERSONNEL ADMINISTRATION
Figure 03, Revision 001, Dated 01.05.09
Officer Application Form Ref .No
(For Official Use)
Medical History
Have you ever signed off from a ship due to medical reasons?
(If yes give details) *yes/no
Name of Vessel Date of occurrence (dd-mmm-yyyy)
Brief Description Of illness/Injury/Accident
DetailsHave you ever suffered from any ailment or disease in the past that is likely to render you unfit for sea service or likely to endanger the health /well being of others onboard?
(If Yes give details) *Yes/No DetailsDo you have any bodily defects or deficiencies?
(If Yes give details) *Yes/No DetailsAre you currently suffering from any ailment or disease that is likely to render you unfit for sea service or likely to endanger the healthy /well being of others onboard?
(If Yes give details) *Yes/No DetailsAre you addicted to alcohol or drug of any kind?
(If Yes give details) *Yes/No DetailsAre you suffering from an ailment that requires you to be on a long -term treatment/medication?
(If Yes give details) *Yes/No DetailsHave you ever deported or banned from entering any country?
(If Yes give details) *Yes/No DetailsHave you ever been convicted of a criminal or drug offence or have any pending offences?
(If Yes give details) *Yes/No DetailsDo you have any obligations towards your current/previous employers?
(If Yes give details) *Yes/No I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge and belief; further, that no certificate of competency or License issued to me has ever been Revoked or Suspended. I also certify that my medical history contained above is true and any false statement or undisclosed Material information about past illness or injury will disqualify me from any employment benefits and claims.
…………………………………….. …………………………………….. dd-mmm-yyyy (Format) Signature
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