KSM NAVIGATION PVT.
LTD
(Approved by D.G. Shipping, Govt. of India)
Recruitment and Placement of Seafarers Licence No.: CHN/048
No.174, Bharathi Salai, Pycrofts Road, Near Express Avenue,
Royapettah, Chennai - 600014. Tamilnadu
E-Mail: [email protected] | [email protected]
Ph: 044 - 48619911, 98400 35090
MLC Compliance & ISO 9001:2015 QMS, Cer fied by IRQS
Date:
Registra on No:
APPLICATION FORM
POSITION : ID NO. (FOR OFFICE USE ONLY) : PHOTO
POSITION APPLIED FOR : AVAILABILITY DATE :
PERSONAL DETAILS :
Name as in Passport (Surname) (First name) (Middle name)
Date/Place of birth Na onality :
( Tel no.:
Home address Mobile no.:
Email id:
Mumbai address if any
Mobile no.:
EDUCATION BACKGROUND :
Qualifica on School / College From To Percentage / Grade
TECHNICAL BACKGROUND :
Degree / Diploma Ins tute / College From To Percentage / Grade
Pre sea training /
Appren ce ship
IDENTITY DOCUMENTS :
Document Country Number Issue date Expiry date Place of issue
Passport Indian
Indian
Seaman book
Other
Do you hold a US Visa ‘C1/D’ ? Yes / No Issue date: Expiry date:
Do you hold Schengen Visa Yes / No Issue date: Expiry date:
Indos. No. (for Indians only): Yellow fever: Expiry date:
Union Membership (MUI / NUSI ) : Expiry date:
FAMILY DETAILS (IF UNMARRIED KINDLY GIVE DETAILS OF FATHER / MOTHER) :
Name Rela on D.O.B PPT No. Place of issue Issue date Expiry date ECNR
NEXT OF KIN DETAILS :
Full name of kin : Rela onship :
( Tel no.:
Address of next of kin : Mobile no.:
Email id:
CERTIFICATES (HIGHEST CERTIFICATE OF COMPETENCY HELD) :
Grade / Class of COC Issuing country Date of passing exam Cer ficate no. Issue date Placed issued Expiry date
DETAILS OF COURSES & CERTIFICATES FOR RATINGS:
Courses Cer ficate no. Issued by Issue Date Expiry Date
FIRE PREVENTION & FIRE FIGHTING (FPFF)
ELEMENTARY FIRST AID (EFA)
Personal Survival Technique (PST)
Personal Survival & Social Responsibility (PSSR)
STSDSDS Course
Oil Tanker Familiariza on (OTFC)
DCE Oil – Support
Chemical Tanker Familiariza on (CTFC)
DCE Chemical – Support
AB / MM Course
Watch Keeping Cer ficate Ra ngs
(Deck/Engine)
Pump Man Course
Cookery Course
MMD Cookery Cer ficate
Fi er Course / Class Cert.
Advanced Fire Figh ng (AFF)
Medical First Aid (MFA) / Medicare
Proficiency in Survival Cra & Rescue Boat
(PSCRB)
Personal Survival & Social Responsibility (PSSR)
SSO (Ship Security Officers Course)
ECDIS
BTM (Renewed every 5 years)
ARPA (Automa c Radar Plo ng Aid)
GMDSS
Refresher & Up Grada on Course for Deck /
Engine Officers
OTHERS :
ISPS Course
Ship Safety Officers Course / Risk Assessment
Ship Maneuvring Simulator
BRM / MRM / BERM (Renewed every 5 years)
Electrical/Electronics for Marine Engineers –
Basic / Advance
FOR ENGINEERS (PLEASE PROVIDE DETAILS) :
Generators Boilers Cranes Framo ( No. of vessels )
TOTAL SAILING EXPERIENCE
Crude Tankers Product Tankers Chemical Tankers Oil / Chemical Others
MEDICAL HISTORY (IF THE ANSWER IS YES TO ANY OF THE BELOW, PLEASE GIVE FULL DETAILS AND ATTACH A
SEPARATE PAGE IF NECESSARY) :
Have you ever signed off a ship due to medical reasons ? Yes / No
Have you undergone any Surgery / Accident Yes / No
Do you have any health disability problems now ? Yes / No
BOILER SUIT SIZE : SAFETY SHOE SIZE :
DECLARATION :
I hereby affirm that all the informa on provided by me in this applica on is true and correct .
Applicant’s Signature Date
FOR OFFICE USE ONLY :
Interviewed on found
Checked on with Mr/Ms _
rep. of (Last employer) & sa sfactory/unsa sfactory.
received sa sfactory/unsa sfactory report regarding his
professional experience & a tude.
By
By
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KSM NAVIGATION PVT. LTD
No.174, Bharathi Salai, Pycrofts Road, Near Express Avenue,
Royapettah, Chennai - 600014. Tamilnadu
E-Mail:
[email protected] |
[email protected] Ph: 044 - 48619911, 98400 35090
Resume Acknowledgment Slip
Validity :
Applica on No. Date:
Company
Rank: Seal Seafarer Signature
(Please give a full record starting with the last vessel on which you served)
D.W.T/ CONTS VSL TYPE OF ENGINES SIGN ON SIGN OFF DURATION REASONS FOR
COMPANY VESSEL NAME B.H.P RANK
TEU’S AGE dd/mm/yy dd/mm/yy yy/mm/dd S/OFF
Flag GRT (Please give full dtls)
