Figure 03 - CV - Sea Staff Application Form

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


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


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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


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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COURSE NAME NUMBER ISSUE DATE

EXPIRY DATE


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


13. SPECIALISED EXPERIENCETYPE FROM TO COMMENTS


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NEW BUILDING

SPECIALISED PROJECTS

SPECIAL TRADES

SHORE EXPERIENCE


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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


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DATE SIGNATURE


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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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Figure 03 - CV - Sea Staff Application Form

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