MSC CREWING SERVICES PRIVATE LIMITED

APPLICATION FORM
1 Position ID/PD No. (For Office Use Only)
_______________________
Position applied for: Deck Cadet
Are you willing to accept any other positions? If YES, which positions would you consider? YES/NO

Are you responding to a media advertisement? If YES, please state which publication YES/NO

From what date will you be available?

2 Personal details

Name: Yadav
Jitesh
(Middle Name)
Date/Place of Birth: 01/03/2005 (Ramlyawala, Rajasthan) Nationality: Indian
Permanent 313-A Ramlyawala Dairy Yogana, Harmada, Jaipur, Rajasthan - 302013
address: Pin Code: 302013
E-Mail: jiteshyadhuvanshi489 Tel No. : Mobile 7976996032
[email protected]
Local address: 313-A Ramlyawala Dairy Yogana, Harmada, Jaipur, Rajasthan - 302013
Pin Code: 302013
E-Mail: jiteshyadhuvanshi489 Tel No. Mobile 7976996032
[email protected]
3a Educational Background
Qualification School / College From To Percentage/ Grade
10th Grade Satyam Sanskar Academy 2020 2021 94%
12th Grade Oxford International School 2022 2023 73.80%

3b Technical Background
Degree/ Diploma Institute/ College From To Percentage / Grade

4 Identity documents
DOCUMENT COUNTRY NUMBER DATE OF ISSUE PLACE OF ISSUE DATE OF EXPIRY
Passport: INDIAN X6870213 11/04/2023 Jaipur 10/04/2033
Seaman Book: National
Panamanian
Liberian
Others
Do you hold a US Visa ‘C1/D’? YES/NO NO Issue Date: Expiry Date:
Do you hold a US Visa ‘B1/B2’? YES/NO NO Issue Date: Expiry Date:
Have you been rejected for any visa applied for? YES/NO NO
If YES, please state the country and reasons
INDOS No: (only for Indians);- 23NM1378 YELLOW FEWER V/T
MUI NO : V/T

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5 Family Details: (If Unmarried kindly give details of Father / Mother)
NAME PASSPORT PLACE OF DATE OF
Relation DOB POB NO. ISSUE
DATE OF ISSUE
EXPIRY
ECNR
Mr. Chouthmal Yadav Father 02/02/ Jaipur NA NA NA NA
Mrs. Sunita Devi Mother 1980
01/01/ Jaipur NA NA NA NA
1982

6 Certificates (Highest certificate of competency held)

Grade/Class Date of Passing Certificate
Issuing Country Date Issued Place Issued Valid Until
Of COC Exam No.
Country

7 Certificates Of Competency issued by other countries (Issued by countries other than in Section 6)

Issuing Country Certificate No. Date Issued Place Issued Valid Until
Panama
Others
8 Details of Courses
Courses Certificate No. Issued By Date Date Of
10100461012400820 IMI Issued
28/03/2024 Expiry
NA
FPFF / AFF
EFA / MFA / MEDICARE 10100461012400820 IMI 28/03/2024 NA
PSCRB
PST 10100461012400820 IMI 28/03/2024 NA
PSSR – Personal Safety & Social Responsibilities 10100461012400820 IMI 28/03/2024 NA
SSO – Ship Security Officers Course
ISPS Course
ROSC – Radar OBS Simulator
ARPA – Automatic Radar Plotting Aid
RANSCO – Radar, Arpa & Navigation Simulator
BTM
SMS / SHS / ERS
ECDIS
Bridge / Engine Resources Management (BRM / ERM)
Ship Master Command and Control Course
GMDSS + endorsement
RUTC – Refresher & Up gradation Course
Container Operations Familiarization
Electrical Familiarization for Marine Engineers
Electronics for Marine Engineers
Instrumentation & Shipboard Control Systems
Automation and Controls
Container Refrigeration
Hydraulics for Engineers (Basic / Advance)
Hazmat (In compliance with STCW-95 Section-B -V/b & V/c & CFR – 49)
CFR-49 and Pneumatics Workshop
Hydraulics
Watch Keeping Certificate Ratings (Deck/Engine)
Applied Electronics (AELC)
Practical Marine Electrical Workshop
Engine Equipment Maintenance Workshop
Basic Electrical and Fluid Technology
Reefer Container and Maintenance Course
MEPC
Operational competence enhancement course for deck
officers
Safety, Environment Compliance & Pollution Prevention
Training for Crew
Vessel Resource Management (VRM)
Electro Technical Officer/ Rating Certificate

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 9 Record of previous service
9 (Please give a full record starting with the last vessel on which you served)

VESSEL D.W.T/ CONTS VSL TYPE OF ENGINES SIGN ON SIGN OFF DURATION REASONS FOR
COMPANY VESSEL NAME B.H.P RANK
TYPE GRT TEU’S AGE (Please give full dtls) dd/mm/yy dd/mm/yy yy/mm/dd S/OFF

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10 For Engineers (Please provide details)

Generators

Purifiers and Boilers

Type of Cranes / No of
Reefer Containers

11 Sailing Experience: (Please advise PRESENT RANK EXPERIENCE on each type of vessel)

Container PCC Reefer Multi Purpose Others

LAST SALARY DRAWN (PLEASE MENTION CURRENCY)

12 Medical history
Have you ever signed off a ship due to medical reasons? YES/NO
Have you undergone any operation in the past? YES/NO
Have you consulted a doctor during the last 12 months for an illness/accident? YES/NO
Do you have any health or disability problems now? YES/NO

(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)

13 General

Have you ever been the subject of a court of enquiry or involved in a maritime accident? YES/NO NO
Have you ever had a professional license suspended or revoked? YES/NO NO

(If YES, please give full details and attach a separate page if necessary)

14 References (Please give the name and address of your current or immediate past employer)

Name of company 1. 2.
Name of person to contact
Address

 No.

15 Review
If immediate employment is not available do you wish to be considered for future vacancies? YES/ NO
If YES, please give any alternative contact details not shown in Section 2

16 Declaration

I hereby declare that the above particulars are true and authorise you to contact the referees listed above.
Date:

Signature
17 BOILER SUIT SIZE: SAFETY SHOE SIZE:

MSCCS-MANN-8.5-01-01 01 MAY 2017 REV-0