Scribd Logo
Upload

Welcome to Scribd!

  • 563 views

    Mid East Application Form New

    Uploaded by

    Shaaz Anaam
    This document contains an application form for a position as a 3E officer on a ship. [1] It requests personal details like name, date of birth, address, contact information, passport and other travel document details, bank account information, education history, professional qualifications, language skills, health certificates, safety equipment, marine training courses, and sea service experience. [2] The applicant is asked to disclose any past or present medical issues and is warned that withholding information can disqualify them from employment. [3] At the end, the applicant certifies that all information provided is true and correct to the best of their knowledge.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Mid East Application Form New

    Uploaded by

    Shaaz Anaam
    563 views8 pages
    This document contains an application form for a position as a 3E officer on a ship. [1] It requests personal details like name, date of birth, address, contact information, passport and other travel document details, bank account information, education history, professional qualifications, language skills, health certificates, safety equipment, marine training courses, and sea service experience. [2] The applicant is asked to disclose any past or present medical issues and is warned that withholding information can disqualify them from employment. [3] At the end, the applicant certifies that all information provided is true and correct to the best of their knowledge.

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document contains an application form for a position as a 3E officer on a ship. [1] It requests personal details like name, date of birth, address, contact information, passport and other travel document details, bank account information, education history, professional qualifications, language skills, health certificates, safety equipment, marine training courses, and sea service experience. [2] The applicant is asked to disclose any past or present medical issues and is warned that withholding information can disqualify them from employment. [3] At the end, the applicant certifies that all information provided is true and correct to the best of their knowledge.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    563 views8 pages

    Mid East Application Form New

    Uploaded by

    Shaaz Anaam
    This document contains an application form for a position as a 3E officer on a ship. [1] It requests personal details like name, date of birth, address, contact information, passport and other travel document details, bank account information, education history, professional qualifications, language skills, health certificates, safety equipment, marine training courses, and sea service experience. [2] The applicant is asked to disclose any past or present medical issues and is warned that withholding information can disqualify them from employment. [3] At the end, the applicant certifies that all information provided is true and correct to the best of their knowledge.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 8

    Mideast: 025 FLEET PERSONNEL ADMINISTRATION

    MIDEAST SHIP MANAGEMENT LTD SEA STAFF APPLICATION FORM


    PHOTO

    APPLICATION FOR POSITION AS

    3E

    OTHER POSITION (IF ANY)

    1. PERSONAL DETAILS
    TITLE MR/MRS/MISS SURNAME FIRST NAME DATE OF BIRTH NATIONALITY COLOUR OF EYES MOTHERS NAME MOTHERS MAIDEN NAME HEIGHT (CM)
    168 NEW DELHI MR. ANAAM SHAAZ 24/08/1982 Indian Black Habiba Khatun

    SEX OTHERS NAMES PLACE OF BIRTH MARITAL STATUS COLOUR OF HAIR FATHERS NAME WEIGHT (KG)

    MALE

    Howrah Married Black Abdus Sattar 77

    NEAREST INTERNATIONAL AIRPORT:

    2. ADDRESS
    NO & STREET CITY POST CODE COUNTRY TEL. NO. MOBILE E-MAIL FAX
    B 1317 Gaur Global Village Crossing Republic, NH 24 Ghaziabad 201009 India 9313349388 9873011720 shaazanaam@gmail.com

    ADDRESS (TEMP.) FROM/TO:


    NO & STREET CITY POST CODE COUNTRY TEL. NO. MOBILE E-MAIL FAX
    Anindita Neogy 250/1 Chiranjiv Vihar Ghaziabad Ghaziabad 01204116056

    3. NEXT OF KIN
    FULL NAME ADDRESS CITY TEL. NO. RELATIONSHIP COUNTRY MOBILE
    9811440420 wife India

    FAX NO. DATE OF BIRTH M M M M SEX F F F F

    4. CHILDREN
    FULL NAME OF CHILD

    Figure 03, Revision 001, Dated 01.05.09 1 of 8

    Mideast: 025 FLEET PERSONNEL ADMINISTRATION

    5. TRAVEL DOCUMENTS
    TYPE PASSPORT SEAMAN BOOK OTHER SEAMAN BOOK US C1/D VISA OTHER VISAS
    C6633972 21/12/2010 19/12/2015 NEW DELHI

    DOCUMENT NO.
    F0136206 CL76302

    ISS.DATE
    28/12/2004 19/10/2005

    EXP. DATE
    27/12/2014 18/10/2015

    ISS. BY (AUTHORITY)
    INDIA MMD

    PLACE OF ISSUE
    KOLKATA KOLKATA

    6. BANK ACCOUNT INFORMATION


    BANK NAME BANK ADDRESS CITY SORT CODE BANK SWIFT CODE ACCOUNT OWNERS NAME ACCOUNT OWNERS ADDRESS ACCOUNT NO BANK TEL. NO COUNTRY BRANCH

    7. EDUCATION
    SCHOOL NAME
    St Thomas Church school

    FROM FROM

    1987

    TO TO

    2000

    SCHOOL NAME

    8. PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY


    CERTIFICATE NAME MEO class 4 NUMBER
    95Z-9016

    ISSUE DATE
    06/07/2008

    EXPIRY DATE
    17/3/2013

    ISSUED BY (AUTHORITY)
    MMD

    ISSUED AT
    KOLKATA

    DANGEROUS CARGO ENDORSEMENT PETROLEUM CHEMICAL GAS

    NUMBER D/O/1/E/10/5011 D/C/1/E/09/3535

    ISSUE DATE 25/11/2010 08/06/2009

    EXPIRY DATE 02/10/2014 07/06/2014

    9. LANGUAGES ENGLISH GERMAN FRANCH SPANISH ITALIAN RUSSIAN


    MARLINS TEST / LEVEL
    FLUENT FLUENT FLUENT FLUENT FLUENT FLUENT GOOD GOOD GOOD GOOD GOOD GOOD FAIR FAIR FAIR FAIR FAIR FAIR POOR POOR POOR POOR POOR POOR

    ISSUED DATE

    RESULT %

    ISSUED BY (AUTHORITY)

    ISSUED AT

    Figure 03, Revision 001, Dated 01.05.09 2 of 8

    Mideast: 025 FLEET PERSONNEL ADMINISTRATION

    10. HEALTH CERTIFICATES & VACCINATIONS


    FLAGE STATE INTERNATIONAL LIBERIAN NORWEGIAN PANAMANIAN NAME YELLOW FEVER ISSUE DATE
    29/08/2005

    NUMBER

    ISSUE DATE

    EXPIRY DATE

    ISSUED BY (AUTHORITY)

    ISSUED AT

    EXPIRY DATE
    29/08/2015

    ISSUED BY (AUTHORITY)
    MMD KOLKATA

    ISSUED AT

    11. SAFETY CLOTHING


    BOILERSUIT SIZE
    M

    BOOTS SIZE ISSUE DATE EXPIRY DATE

    12. MARINE COURSES


    COURSE NAME
    PERSONAL SURVIVAL BASIC FIRE FIGHTING ADV. FIRE FIGHTING ELEMENTARY FIRST AID MEDICAL FIRST AID MEDICAL CARE PERS. SAFETY & SOC. RESP. PROF. IN SURVIVAL CRAFT & RESCUE BOATS FAST RESCUE CRAFT G.M.D.S.S. A.R.P.A. (Management level) RADAR OBSERVATION HAZMAT OIL TANKER ADVANCE OIL TANKER CHEMICAL TANKER ADVANCE OIL TANKER GAS TANKER ADVANCE GAS TANKER CRUDE OIL WASHING INERT GAS PLANT ISM CODE SHIP SECURITY OFFICER BRIDGE TEAM MANAGEMENT DP INDUCTION DP SIMULATOR

    NUMBER

    ISSUED BY (AUTHORITY)

    ISSUED AT

    03029 MFA0020701725 PSSR010505444 03240

    12/01/2007 27/01/2007 04/05/2005 19/01/2007

    IIPM MMA KOLKATA MMA KOLKATA IIPM

    KOLKATA KOLKATA KOLKATA KOLKATA

    OTF/018/05 CTF/F-4973/2009

    22/10/2005 06/06/2009

    MMA KOLKATA MTA

    KOLKATA MUMBAI

    Figure 03, Revision 001, Dated 01.05.09 3 of 8

    Mideast: 025 FLEET PERSONNEL ADMINISTRATION

    BRIDGE / ENGIINE ROOM RESOURCE MANAGEMENT. SHIP HANDLING INTERNAL AUDITORS COURSE

    12. MARINE COURSES (CONTD)


    COURSE NAME NUMBER ISSUE DATE EXPIRY DATE ISSUED BY (AUTHORITY) ISSUED AT

    13. SPECIALISED EXPERIENCE


    TYPE NEW BUILDING SPECIALISED PROJECTS SPECIAL TRADES SHORE EXPERIENCE FROM TO COMMENTS

    Figure 03, Revision 001, Dated 01.05.09 4 of 8

    COMPLETE SEA SERVICE DETAILS


    ( LAST VESSELS FIRST ) NAME: RANK: SIGNED ON 17/01/2006 13/03/2006 01/09/2008 16/06/2009 18/02/2010 06/01/2011 SIGNED OFF 02/03/2006 31/12/2006 30/12/2008 03/10/2009 13/08/2010 21/04/2011 PERIOD IN MONTHS (eg 4.2)
    MOL MOL MOL THOME SHIP MANAGEMENT GREAT EASTERN EXECUTIVE SHIP MANAGEMENT

    AVALIABILITY DATE: TYPE OF VESSEL


    VLCC CONT CONT OIL/CHEM OIL OIL/CHEM

    ENGINE TYPE GT ( ENGINEERS ONLY)


    MAN B&W SULZER MAN B&W MAN B&W MAN B&W MAN B&W

    COMPANY NAME

    RANK 5E 5E 4E 4E 3E
    3E

    VESSEL NAME

    BHP

    KW

    MT OTOWASAN
    MV MOL ENDURANCE MV MOL THAMES MT SITEAM ADVENTURER MT JAG LATA MT ALPINE MIA

    1/17
    9/20 4 3/18 5/24 3/17

    160292

    27160 50049 37180 8200 11473 9610

    53096 50628 26751 57508 29266

    REFERENCE CONTACT DETAILS


    COMPANY NAME ADDRESS PHONE NO. FAX/E-MAIL CONTACT PERSON I declare that the information I have given is, to the best of my knowledge, true and complete. I also declare that the documents submitted are genuine, given and sign by persons whose names appear on them.

    17/11/2011
    DATE

    SHAAZ ANAAM
    SIGNATURE

    Officer Application Form


    Medical History Have you ever signed off from a ship due to medical reasons?

    Ref .No (For Official Use)

    (If yes give details) Name of Vessel Date of occurrence (dd-mmm-yyyy)

    *yes/no

    Brief Description Of illness/Injury/Accident

    Details Have 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) Do you have any bodily defects or deficiencies?

    *Yes/No Details

    (If Yes give details)

    *Yes/No Details

    Are 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) Are you addicted to alcohol or drug of any kind? *Yes/No Details

    (If Yes give details) Are you suffering from an ailment that requires you to be on a long -term treatment/medication? (If Yes give details) Have you ever deported or banned from entering any country?

    *Yes/No Details

    *Yes/No Details

    (If Yes give details)

    *Yes/No Details

    Have you ever been convicted of a criminal or drug offence or have any pending offences?

    (If Yes give details) Do you have any obligations towards your current/previous employers?

    *Yes/No Details

    (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

    You might also like