GOVERNMENT OF INDIA

MINISTRY OF SHIPPING
GOVENRMENT SHIPPING OFFICE
APPLICATION FOR CONTINUOUS DISCHARGE CERTIFICATE (CDC)
Applicetion No. Application Date :14-DEC-2022
:SMO(K)/2022/42685
Office Applied To SHIPPING MASTER OFFICE KOLKATA
Personal Details
Name of the Candidate :KULKARNI KSHITIJ SUDARSHAN
Father's name :Sudarshan Mukund Kulkarni
Sex Male Date of birth :20-JAN-2002
Place of birth : Dombivali, Thane Nationality : Indian
INDOS No. 19NMO541 Indos Issue Date :30-JUL-2019
Height (in cms) 184 Colour of eyes : black
Colour of hair : black
Identification Marks :Scar on forehoad
Valid Passport No. :W7013283 Passport issue Place :Mumbai
Passport Issue Date :03-NOV-2022 Passport Expiry Place :02-NOV-2032
10th Standard Pass Certificate Details
Name of Board :CBSE
Year of Passing :2017 Certificate No. :1318601
Permanent Address Details
House No. : Nisarg Street :Bramhan Ali Road
Village/Post Office :Roha District : Raigad
State Maharashtra Pin Code :402109
Phone No. with STD Code: 9820212396 Nearest Police Station Roha police station
Email ID :kk_2012@yahoo.com Mobile No. :9820212396
Next-Of-Kin Details
Name of Next of Kin : Neha Nitin Avalaskar House No. Nisarg
Relationship with Seafarer: Maternal Aunt Village/Post Office/Tehsil : Roha
Street :Bramhan AliRoad State Maharashtra
District Raigad Phone No. with STD Code :9890700868
Pin Code :402109

STCW Course Details

Sr. No. Name of course Certificate No. Date of issue Name of Institute

1 Basic Safety Training (STCW-BASIC) 20100461012201913 25JUN-2022 TS Rahaman

Security Tmg. for Seafarer with Designated Security Duties 20100466212202112 30-JUN-2022 TS Rahaman
(STSDSD)
Medical Certificate
Name of the Doctor :Shrikant Birbale
DGS Approval No. of the Doctor : MAG/MUM/072015 Place of issue of Medical Certificate Navi Mumbai
Date of issue of Medical Certificate :30-JUN-2022 Date of Expliry of Medical Certificate :29-JUN-2024
Fees Details
Amount (Rs.) 700 Payment Mode ePayment
Payment Detalls Fees not paid

Attached Document
Sr. No. Documents to be Uploaded
1 Scan copy of signed online application
Passport size (3.5 cm X 3.5 cm) photograph with clear white background face covering 70%
2
3 Scanned signature of seafarer
4
Coloured scanned copy of original Passport (Pages where personal detials, Photo,address details and signature of passport authority are
displayed)
Coloured scanned copy of original 10th Standard Pass Certificate/ Marksheet
6 Coloured scanned copy of original Medical Fitness Certificate from DGS Approved Doctor (Appendix IV)
7
Coloured scanned copy of original permanent address proof (Any one of them Passport,Aadhaar Card, Election Commission Photo iD card.and
Permanent Driving License)

Declaration
Declaration &Undertaklng of Candidate (KULKARNIKSHITJ SUDARSHAN)

Report generated on ; 14/12/2022 12.17 PM Page 1 of 2

 nereoy oeclare that all the
statements made in this application are true and
concealed/distorted. complete to the best of my knowledge and belief and nothing has been
dis am and an
have not Submitted decare that I have not previously been issued with a Continuous
application for CDC to any other Shipping Discharge Certificate-cum-Seafarer's ldentity Document (CDC) and
o ohtain Master in India.
any time, lam found to have concealed/distorted any material information and the Shipping Master has reasons to
e Merchant
9ot D by presenting false or erroneous information, my CDC believe that
will be cancelled/suspended forthwith as per the provisions contained in Rule
I
Shipping (Continuous Discharge Certificate) Rule,
2017 as amended.

Agree.
Place Mumbaui..
Date 14-DEC-2022
Signature of the Candidate:Kdkarhi.. .
Name of the Candidate :KULKARNI KSHITIJ SUDARSHAN

SMO(KV2022/42685

: 14/12/2022 12.17 PM
Report generated on Pag 2 of 2