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Am S Applicationform

This 4-page document is a biodata/pre-joining form for officers applying to Admiral Marine Services Pvt. Ltd. It requests personal details, licenses and certifications, medical history, previous sea service experience, and references from the applicant. The form also includes sections for the company to record an initial interview and assessment of the applicant.

Uploaded by

Divay Bakshi
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© © All Rights Reserved
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50 views5 pages

Am S Applicationform

This 4-page document is a biodata/pre-joining form for officers applying to Admiral Marine Services Pvt. Ltd. It requests personal details, licenses and certifications, medical history, previous sea service experience, and references from the applicant. The form also includes sections for the company to record an initial interview and assessment of the applicant.

Uploaded by

Divay Bakshi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Page 1 of 4

ADMIRAL MARINE SERVICES PVT.LTD

BIODATA / PRE JOINING FORM - OFFICERS

PERSONAL DATA
First Name Middle Name Surname

Nationality Date of Birth Place of Birth

Post Applied For Willing to Accept Lower Rank? Available From:


Yes / No / / /
Permanent Address: Present Address:

PIN Code: PIN Code:


STD Code: Phone Number: STD Code: Phone Number:
Email: Mobile No:
Passport No: Date of Issue Place of Issue Date of Expiry ECNR Minimum 4
Blank Pages
Yes/No Yes/No
U.S. VISA MUI No: Membership
C1/D : Yes / NO
Seaman’s Book (CDC) Number Date of Issue Place of Issue Expiry Date Remark
Indian
Norwegian
Panamanian
Vanuatu
Liberian
Others

License Grade Number Date of Issue Place of Issue Date of Expiry


Indian
U.K.
Singapore
Australian
Panamanian
Vanuatu
IOM
Liberian
Others
GMDSS
GMDSS Endorsement
Civil Status: Single/ Married/ Separated/ Divorced/ Widowed
Full Name of Next of Kin: Relationship:
Address of Next of Kin:
Phone-STD Code: Phone No.:
Height : Cm : Weight : Kg :
Boiler Suit Size ( S , M , L , XL , XXL) : Shoe Size (6, 7, 8, 9, 10, 11) :
Page 2 of 4

Family Name D.O.B PPT.No. D.O.I Place of Issue D.O.E ECNR


Data
Wife

Child M/F
Child M/F
Child M/F
* Tick Validity Visa USA UK Australia Brazilian Others
Date (B1/B2)

Details of Courses & Certificates Number Date of Issue Date of Expiry Issued by
STCW Courses:
Basic Fire Fighting (BFF)
Proficiency in Survival Technique (PST)
Elementary First Aid (EFA)
Personal Survival & Social Responsibility
(PSSR)
Advanced Fire Fighting (AFF)
Proficiency in Survival Craft & Rescue Boat
(PSCRB)
Fast Rescue Boat (FRB)
Medical First Aid (MFA)
Medicare
Radar Observer / ARPA
Radar Simulator (RANSCO) / ENS
Ship Handling Simulator
Tanker courses:
LCHS
Oil Tanker Familiarization (OTFC)
Chemical Tanker Familiarization (CTFC)
Gas Familiarization (GTFC)
Petroleum Tanker Safety (STPOTO)
Chemical Tanker Safety (CHEMCO)
Gas Tanker Safety (GASCO)
Engine Room Simulator (ERS)
Other Courses:
Hazmat Course
Bridge Team Management (BTM)
Others:
Yellow Fever
SSO Course
INDOS NO
Revalidation course

Dangerous Cargo Nationality Grade/ Level Number D.O.I Place of D.O.E


Endorsements I / II Issue
Oil
Chemical
Liquefied Gas
Pre Sea Training / Apprentice ship
Name of Institute / College From To Type of Degree

S.S.C (10th) Marks : % H.S.C. (12th ) Marks : % H.S.C. (PCM) %


Page 3 of 4

Previous Sea Service (Commencing from Last Vessel) (PLEASE FILL THE GRT/KW AS PER STCW REQUIREMENT) (1KW = 1.37 BHP)
Sr.No. Name of Company Name of Type GRT KW Engine type UMS Rank From To Total Reason for
Vessel Y/N MM/D S/OFF
D
1

10

11

12

13

14

Where did you get to know ADMIRAL MARINE SERVICES


a. Word of mouth b. Print media (state which) c. Contacted by AMS Staff d. Web Sites
 _______________  _______________  _______________  _____________
Page 4 of 4
Medical History
(a) Have you ever signed off from a ship due to Medical reasons, Yes/No
( If Yes give details)
Name of Vessels Date of Occurrence

Brief Description of Illness / Injury/ Accident

(b) Did you suffer or Are you Presently suffering from any Disease likely to render you Yes/No
unfit for Service at Sea or likely to endanger the health of others on board.
(c) Are you addicted to alcohol or drugs of any kind. Yes/No
(d) Have you suffered from following
Malaria Diabetes Epilepsy Nervous Disability

(e) Did you ever undergo psychiatric treatment : Yes / No

Reference
Sr. Name of the company PIC Designation Phone No
No
1
2
3
For Office Use

I warrant and represent that:


1. The foregoing details are true and accurate and complete
2. There are no contractual or other restrictions (other than official visa/ work.Permit Approvals) or health conditions that may in any way pr
Prevent or restrict me form being employed by you and fully performing my work and duties; and
3. I apply for employment with you by my own free will without any inducement or representative from you or your agents.
4. Future that no Certificate of competency or license issued to me has ever been revoked or suspended.
5. 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.

Date___________ Rank_________________ Signature of Seaman ___________________

(FOR OFFICE USE ONLY) INITIAL INTERVIEW (Tick as applicable)


Original licenses sighted [ ] Checked by [ ]
STCW and Training Certificates sighted [ ] Checked by [ ]
Experience confirmed by interview [ ] Checked by [ ]
Other details confirmed by interview [ ] Checked by [ ]

A : Professional knowledge VG / G / S / P B : General awarness VG / G / S / P


C : Attitude/CS VG / G / S / P D : FE VG / G / S / P
E : Safety awareness VG / G / S / P F : LTP VG / G / S / P

Assessment & Evaluation by , Name: ___________________ Date :_________ Signature______________


Approved By CEO Yes [ ] No [ ]
Approved By Head Office for Top 4 Officers Yes [ ] No [ ]

8-Jun-23

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