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Passport size
Photograph
Height Weight (In KGS) Smoker / Nonsmoker Yellow Fever Union Membership
(In CMS) Blood Group Veg. / Non - Veg. DOI DOE BATCH /LOT No.
YES NO
Boiler Suit Size : MED / LARGE / XL / XXL Shoe Size :
Address :
Tel. :
....................Family Data....................
Relationship First Name Last Name DOB Passport No. Place Issued Valid until
Spouse
Child M / F
Child M / F
Indicate Type of Valid Visa : USA CANADA BRAZIL UK OTHERS
*
Anniversary Date :
* Please check if visa and all documents are valid for the tenure on board, plus 6 months.
FORM NO : EMSPL / 02 / 2013
REV. NO : 02 / 2016
Applicant’s Signature
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(B) Education / Other Qualifications :
EDUCATIONAL QUALIFICATION
Result Grade (1st, 2nd,
10 + 2 / Degree Institution / University Year of Passing 3rd or A, B, C etc)
CERTIFICATES OF COMPETENCY :
Highest Competency Certificate Held
Date of Passing Examination
Issuing Authority Grade Certificate No. DOI Place Issued Valid until
National (Country)
Panamanian
Marshall Island
Hongkong
Others
GMDSS
GMDSS (Endorsement)
LIST OF S.T.C.W. 1995/2010 OTHER COURSES DONE
Courses Cert. No. 95 Cert. No. 2010 Date of Issue Date of Expiry
1) FPFF / Advanced Fire Fighting
2) Proficiency in Survival Craft & RB / PST
3) Elementary / Medical First Aid / Medicare
4) PSSR
5) CTFC / CHEMCO
6) OTFC / TASCO
7) GTFC / GASCO
8) LCHS : (Management / Operational)
9) Ship Manouvering Simulator Course
10) Radar Observer Course / ARPA
11) Radar Simulator Course / RANSCO
12) BTM / BRM
13) ISPS (SSO / STSDSD) Course
14) NIS Familiarisation Course
15) C.O.C. Revalidation Course
16) INDOS NO (Mandatory Requirement)
17) ECDIS General / Type Specific
18) STCW 2010 Refresher Courses
Applicant’s Signature [ 2 / 10 ]
(C) SEA SERVICE : (Start From Last Vessel Served)
Flag of Type of Engine make & model & BHP/KW (For Engineers) DWT (D) From To Total
Name of the Company Name of the Vessel Rank
Vessel Vessel Cargoes Carried (For Deck Officers) GRT (G) dd/mm/yy dd/mm/yy M/D
Non Fleet Management Vessels
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Remarks :
Applicant’s Signature
(D) Experience Matrix of Engineer Officer
Please mark ‘Y’ against your rank in the cell, if that experience is applicable to you
S.No. Crane Make C/E 2/E 3/E 4/E E/O Any Breakdown experience / Remarks
Experience on Deck / Cargo Machinery
1 Haaglund
2 Liebherr
3 IHI
4 Mitsubishi
5 NMF
6 Atlas
7 BLM
8 MacGregor
9 Any Other
Grab Make
1 SMAG Peiner
2 ORTS
Experience on Reefer Machinery / Reefer Container
1 Direct System
2 Indirect System
3 Carrier Transicold
4 Thermoking
5 Daikin
6 Mistubishi
7 Any Other
Experience on Oil / Chemical / Gas Tankers
1 Framo Pumps
2 Centrilina Pumps
3 Steam Turbines
4 Any Other
Experience on Propulsion System / Manoeuvering System
1 CPP
2 Bow/Stern thruster
3 Twin Screw
4 NOR Control
5 Kongsberg
6 Any Other
Experience on Auxilliary Engines
1 Yanmar
2 Daihatsu
3 Sulzer
4 MAN B&W
5 Cummins
6 Caterpillar
7 Pielstik
8 Volvo Penta
9 Any Other
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S.No. Crane Make C/E 2/E 3/E 4/E E/O Any Breakdown experience / Remarks
Experience of major overhaul / breakdown
1 Drydock
2 M/E Turbocharger
3 M/E Governer
4 M/E Cyl. Liner
5 Thrust Block
6 A/E Crankshaft
7 Alternator overhaul
8 Steering Gear
9 Any Other
Experience in Disaster Management
1 Grounding
2 Collision
3 Oil Spill
4 Crank Case Explosion
5 Scavenge Fire
6 Engine Room Fire
7 Cargo Fire
8 Abandon Ship
9 Steering Failure
10 Any Other
Experience in PMS
1 AMOS
2 TM Master
Additional Comments to Explain above
Applicant’s Signature
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(E) Experience Matrix of Deck Officer
Please mark ‘Y’ against your rank in the cell, if that experience is applicable to you
S.No. Description M CO 2O 3O Cdt Any Breakdown or incident experience / Remarks
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S.No. Description M CO 2O 3O Cdt Any Breakdown or incident experience/ Remarks
Experience in PMS
1 AMOS
2 TM Master
Additional Comments to Explain above
Applicant’s Signature
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(F) GENERAL :
(1) Have you ever been denied a foreign visa or been deported from any country ? Yes / No
If yes, state which country and reason (if known) :
(2) Have you been the subject of a court of enquiry or involved in a maritime accident ? Yes / No
If yes, please attach details
(Collision, Grounding, Fire, Pollution)
(3) Have you ever signed off a ship due to medical reason within last 3 years ? Yes / No
If yes, please provide following details :
Name of vessel Date of occurrence Illness Place of occurrence
(4) Have you ever been involved in any criminal activity or have pending criminal case ? Yes / No
If yes, please provide details
______________________________________________________________________________________________
______________________________________________________________________________________________
(5) Have you ever been involved in any navigational incidents in last 24 months ? Yes / No
If yes, please provide details
______________________________________________________________________________________________
(6) Are you currently under medical treatment or taking medication for existing conditions ? Yes / No
If yes, please provide details
Comments on above ____________________________________________________________________________
______________________________________________________________________________________________
(7) Last drawn salary in USD :
Please provide copy of your Account of wages.
(8) References
Please give referees from two recent employers who we may contact for references
Reference 1 Reference 2
Name of Company
Name of Person to contact
Address
Country
Telephone
I Do hereby declare that all information furnished is true to best of my knowledge and belief.
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(G) FOR OFFICE USE ONLY
This form shall be used to document the observations made during the interview. The interviewer may provide
his recommendations for additional training if required.
1 Dress
2 Grooming
3 Body language
4 Communication skills
Comments if any :
Comments if any : (
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(H) FOR OFFICE USE ONLY
Name : Sign
Comments :
Regd. Office : Elegant Marine Services Private Limited :602, The Great Eastern Galleria, Sector-4, Nerul, Navi Mumbai- 400 706
CorporateOffice : Elegant Marine Services Private Limited : 601/A, Elegant Business Park, Off Andheri Kurla Road,
Near Kohinoor Continental Hotel, Andheri (E), Mumbai - 400 059. India
Tel. : (+91 22) 3090 6100 z Fax : (+91 22) 3090 6200 z E-mail : seacareer@elegantship.com
Branch Offices : DELHI : Tel. (0124) 469 0400 z KOLKATA : Tel. (033) 4006 1030 Fax (033) 4006 1039
KOCHI : Tel. (0484) 406 3666 Fax (0484) 406 3665 z CHENNAI : Tel. (044) 2431 4744 Fax (044) 2431 4746
VIZAG : Tel. (0891) 274 9775 Fax (0891) 271 9775 z PATNA : Tel. (0612) 220 6788 Fax (0612) 220 6792
LUCKNOW : Tel. (0522) 402 4685, 402 4686, 407 6494 z CHANDIGARH : Tel. (0172) 464 7015
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