COMPANY WORK FORM Form No. F.6.

2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD

VDATE AVAILABLE: 15 May 2018

POSITION APPLIED FOR: Chief Officer
FULL NAME: ANKIT BORDIA ATTACH
SURNAME: BORDIA PHOTO
FIRST NAME: ANKIT HERE
MIDDLE NAME(S)
PERSONAL DETAILS
DATE OF BIRTH 28 OCT 1985 PLACE OF BIRTH NATIONALITY HEIGHT 177 CMS
JAIPUR (RAJ) INDIAN
WEIGHT 74 KGS HAIR COLOUR BLACK EYE BROWN
COLOUR
MARITAL STATUS MARRIED SPOUSE’S NAME SURBHI BORDIA No. of ONE
Children
FATHER’S NAME RAJESH K. MOTHER’S NAME MANJU BORDIA NEXT OF SURBHI
BORDIA KIN BORDIA
HOME ADDRESS 23 H ROAD, BHUPALPURA, TEL. No. +91-294-2410105
(PERMANENT) UDAIPUR (RAJ), INDIA- 313001
OTHER ADDRESS TEL. No.+91-9784163446

E-MAIL: Skype: freshankit Homeport: Mob No. +91-9784433446

SIZZLINGANKIT@GMAIL.COM UDAIPUR
LICENCES / DOCUMENTS HELD
ITEM No. I S S U E D EXPIRING GRADE
DATE PLACE BY DATE
NATIONAL LICENCE IFOO14287 18/01/2018 MUMBAI DG SHIPPING 13/12/2022 MASTER
FG
STCW ENDORSEMENT
MARSHALLS ISL. ENDORSEMENT MH484414 04/08/2016 MUMBAI MAR. 03/08/2021 SEAMAN
ADMIN. BOOK
LIBERIAN ENDORSEMENT
OTHER LICENCE
PASSPORT L5314455 17/12/2013 JAIPUR GOVT OF 16/12/2023
INDIA
NATIONAL SEAMAN’S BOOK/CDC MUM139577 07/09/2006 MUMBAI DG SHIPPING 17/04/2026
OTHER SEAMAN’S BOOK / CDC
U.S.VISA 20160881230 31/03/2016 NEW DELHI US GOVT 27/03/2021
002
YELLOW FEVER VACCINATION D42794 14/06/2016 MUMBAI GOVT OF 23/06/2026
INDIA
P.R.C. No. (Filipino Crew only)
National data base of seafarers INDOS
Certificate No. (Indian personnel only)
CERTIFICATES HELD
ITEM No. ISSUED EXPIRING ISSUED BY
BASIC SAFETY TRAINING (*IF ONE CERTIFICATE)
PERSONAL SAFETY & SOCIAL RESPONSIBILITIES* PSSR/022/ 05/05/2006 TS CHANAKYA
2006
PERSONAL SURVIVAL* PST/006/2 07/04/2006 TS CHANAKYA
006
SURVIVAL CRAFT HANDLING*
FIRST AID AT SEA (ELEMENTARY LEVEL)*
PROFICIENCY IN SURV.CRAFT/ RESCUE BOAT (PSCRB) 080157 22/02/2008 LBS COLLEGE
ADVANCED / SHORE-BASED FIREFIGHTING 3751 12/04/2008 TS CHANAKYA
PETROLEUM TKR SAFETY – BASIC/ GEN OIL TKR FAM.
MEDICAL FIRST AID SMI/MFA/ 16/02/2008 SNS MARITIME
957/2008
SHIP MASTERS MEDICARE/ADVANCED MEFA 648 27/04/2012 SEI
EDUCATIONAL
TRUST
PETROLEUM TKR SAFETY – ADVANCED/SPECIALISED STPOTO/0 28/02/2013 OERC
05/2012-
13
COW / IGS
DANGEROUS CARGO ENDORSEMENT - OIL DCN02M 22/12/2016 21/12/2021 MMD MUMBAI

Rev. 3 dated 30/09/15

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COMPANY WORK FORM Form No. F.6.2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD
UM16003
085
CHEMICAL TANKER SAFETY SCTO/413 11/04/2013 OERC
3/2013-14
LIQUIFIED GAS FAMILIARISATION
LIQUIFIED GAS SPECIALISED/ADVANCED COURSE NATCOM/ 24/10/2013 NATCOM
GASCO/0
93/2013
DANGEROUS CARGO ENDORSEMENT - LIQUIFIED GAS DCN02M 13/09/2017 12/09/2022 MMD MUMBAI
UM17004
189
LICOS (FOR OIL/ CHEMICALS) 130069 26/04/2013 LBS COLLEGE
LICOS (FOR LIQUIFIED GAS) LNG- 24/08/2012 BSM MARITIME
SHELL/08-
12/44/220
LIQUIFIED GAS-SPECIFIC FIRE FIGHTING – PLS SPECIFY
SIGTTO 000420 09/04/2009 SIGTTO BUREAU
VERITAS
STCW ENDORSEMENT IMERPAT/R 02/12/2016 IMER
UTD/29-
2016-010
ARPA
R.O.C. / RANSCO / RADAR SIMULATOR SMC/RAN 31/03/2012 SEACOM
SCO/1195 MARINE
SATCOM
\\\

APPLICANTS NAME: _________________________________________________________

CERTIFICATES HELD (CONTINUED)

ITEM No. ISSUED EXPIRING ISSUED BY
GOC / GMDSS GMDSSM 02/02/2018 01/02/2023 MMD
UM18008 MUMBAI-
104
ECDIS ECDIS/37- 27/09/2013 IMT CENTRE
13/487
SHIP MANOEUVERING/SHIP HANDLING SIMULATOR 953 04/11/2017 ANGLO
EASTERN
SHIP SECURITY OFFICER IMERPAT/ 25/05/2016 IMER
SSO/118-
2016/005
ISPS FAMILIARISATION
SHIPBOARD SAFETY OFFICER SBSO/27/0 04/06/2016 03/06/2021 AIMS
6/2016 INSTITUTE
ENGINE ROOM SIMULATOR
ENGINE ROOM RESOURCES MANAGEMENT
HUMAN RELATIONS
QUALITY AND SAFETY MANAGEMENT
RISK ASSESSMENT / RISK MANAGEMENT
MARINE ACCIDENT/INCIDENT INVESTIGATION
MANAGEMENT OF CHANGE
ENVIRONMENTAL COURSE / ISO 14001
MLC/LSC MARITIME LEADERSHIP COURSE
MARPOL I
MARPOL II
MARPOL VI
MARITIME ENGLISH
MLC 2006 IMERPAT/ 02/12/2016 IMER
MLC/29-
2016/010
BRIDGE TEAM MANAGEMENT SSMLBTM 06/03/2013 SEATRAIN
2013004
BRIDGE RESOURCES MANAGEMENT SPL/03- 23/01/2009 IMT CENTRE
09/2830

RECORD OF PREVIOUS SERVICE (VERIFIED AGAINST SEAMAN’S BOOK ENTRIES)

Rev. 3 dated 30/09/15

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COMPANY WORK FORM Form No. F.6.2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD
COMPANY VESSEL’S TYPE/ DWT M/ENG’S BHP/ UMS RANK FROM TO MONTHS
NAME BUILT TYPE ( Y-N)
FSMHK GAS VLGC 49609 Y C/O 13- 15-
COMMERCE (LPG) Feb- Apr-
18 18
FSMHK GAS VLGC 49609 Y C/O 15- 24-
COMMERCE (LPG) Feb- Aug-
17 17
FSMHK PRODUCT Y C/O 16- 22-
TANKER Jun- Oct-
VICTORY 47225 16 16 4.5
SHELL SHIPPING OIL/ Y 2/O 8- 14-
CHEMICAL Jun- Sep-
BATISSA 51463 13 13 3.5
SHELL SHIPPING OIL/ Y 2/O 5- 24-
CHEMICAL Sep- Jan-
BURSA 51463 12 13 5.0
SHELL SHIPPING VLGC Y 3/O 22- 6-
(LNG) May- Oct-
BEBATIK 51579 11 11 4.5
SHELL SHIPPING VLGC Y 3/O 16- 17-
(LNG) Sep- Jan-
GALLINA 72781 10 11 4.5
SHELL SHIPPING VLGC Y 3/O 17- 6-
(LNG) Mar- Jun-
LNG BONNY 98954 10 10 3.0
SHELL SHIPPING VLGC Y 3/O 16- 16-
(LNG) Aug- Dec-
SS GALEA 72781 09 09 4.0
SHELL SHIPPING VLGC Y 3/O 10- 31-
(LNG) Feb- May-
SS GRANOSA 84823 09 09 4.0
SHELL SHIPPING VLGC Y 3/O 12- 16-
LNG/C (LNG) Sep- Dec-
GRACILIS 84823 08 08 3.5
SHELL SHIPPING VLGC Y DECK 2- 31-
(LNG) CADE Nov- Jan-
GALLINA 72781 T 07 08 3.0
SHELL SHIPPING VLCC Y DECK 28- 25-
CADE Apr- Sep-
OLIVA 300000 T 07 07 5.0
SHELL SHIPPING PRODUCT Y DECK 17- 25-
TANKER CADE Nov- Mar-
HAMINEA 49900 T 06 07 4.5

Rev. 3 dated 30/09/15

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COMPANY WORK FORM Form No. F.6.2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD
APPLICANT’S NAME: ___________________________________________________________________
ACTUAL TIME SERVED IN MONTHS
OBO / CHEM. / BULK
RANK LNG LPG CRUDE OIL PRODUCT CARRIER/
TANKER TANKER OTHER
MASTER OR CH. ENG.
C/OFF OR 1A/E 9 MONTHS 4.5 MONTHS
2/OFF OR 2A/E 9 MONTHS
3/OFF OR 3A/E 23 MONTHS
GAS/CARGO ENGINEER
CADET/JR.ENG 3 MONTHS 5 MONTHS 4.5 MONTHS
ETO / ELEC (PLS STATE)
PMN / FITTER
OTHER RANK

ALLOTMENT DETAILS
SURNAME BORDIA
NAME ANKIT
MIDDLE NAME
DATE OF BIRTH 28 OCTOBER 1985
RELATIONSHIP SELF
ADDRESS 23 H ROAD, BHUPALPURA, UDAIPUR (RAJ) - 313001, INDIA
NAME OF BANK HDFC BANK
ACCOUNT No. 01191090000025 IFSC CODE: HDFC0000119
SSS No. (Filipino crew only)
TIN No. (Filipino crew only)

WIFE & CHILDREN’S NAME S DOB POB PASSPORT NO. DATE OF ISSUED AT
ISSUE EXPIRY
SURBHI BORDIA 03/06/87 Ajmer M7838388 01/04/15 31/03/15 JAIPUR
ARHANT BORDIA 26/01/15 Kolkata M7838403 01/04/15 31/03/20 JAIPUR

How long did you stay at your previous company? 2.5 YEARS
Wages on last vessel? 10400 USD
Trade route of vessels? WORLDWIDE
Who referred you to the company? CAPT PATANKAR
Any relatives with the company? NO
If yes, who?
ANY OTHER INFORMATION ABOUT YOURSELF:
2 YEARS SHORE EXPERIENCE WORKING IN SHELL VETTING TEAM, LONDON.
FIND ATTACHED RESUMEFOR MORE DETAILS.

UNION MEMBERSHIP NO.: DATE :

DOE:
ALL APPLICANTS
DATE APPLICATION FILLED OUT 27/04/2018

SIGNATURE OF APPLICANT

FULL NAME IN BLOCK CAPITALS ANKIT BORDIA

Rev. 3 dated 30/09/15

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