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SUBMISSION FORM

POSITION APPLIED

DATE OF

APPLICATION

INDOS NUMBER DATE OF READINESS
Are You Willing To Accept Any Other Position? YES NO If Yes, Which Positions Would You Consider?

PERSONAL DETAILS

NAME SURNAME
DATE OF BIRTH PLACE OF BIRTH
HEIGHT IN CMS. WEIGHT IN KGS.
COLOR OF HAIR BOILER SUIT SIZE
FOOD HABIT NATIONALITY
TELEPHONE: MOBILE
E-MAIL 1: E-MAIL 2:
PERMANENT ADDRESS: PRESENT ADDRESS:
CITY & PIN CODE: CITY & PIN CODE:

PASSPORT DETAILS

NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY
PASSPORT
US C1/D VISA
ECNR YELLOW FEVER

CONTINUOUS DISCHARGE CERTIFICATE(S)

CDC NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY
INDIAN
PANAMA
LIBERIAN YELLOW FEVER
OTHERS

LICENCE / CERTIFICATE OF COMPETENCY

CDC GRADE NUMBER DATE OF ISSUE DATE OF EXPIRY DATE OF REVALIDATION

STCW 95
YES OR NO


INDIAN
UK / AUS
SINGAPORE
HONGKONG
LIBERIAN
PANAMA
OTHERS

STCW AND OTHER CERTIFICATE(S)

STCW COURSES CERTIFICATE NO. DATE OF ISSUE DATE OF EXPIRY PLACE OF ISSUE ISSUING AUTHORITY
/ INSTITUTE
PSSR
EFA/MFA/MEDICARE (First Aid)
PST / PSCRB (Survival)
FP & FF / AFF (Fire Fighting)
ROC
ARPA
GMDSS
GMDSS ENDORSEMENT
SSO
COOKERY COURSE
W/K CERT. FOR RATINGS
SIMULATOR TRAINING
ENGINE SIMULATOR
BTM
ECDIS
ICE NAVIGATION
BRM / ERM / VRM
TANKER COURSES
TASCO / TANKER FAM.
CHEMCO / CHEM FAM.
GASCO / GAS FAM.
DCE PETROLEUM
DCE PETROLEUM
DCE GAS
LIQUID CARGO SIM

 

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