Form # 02

PAGE 01/05

NauticFleet Private Limited

(As agents only) t o
ho
RPSL License No.: MUM-162072
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DOI: 02/11/2021 DOE: 02/11/2026 ol nd
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SEAFARER EMPLOYMENT FORM ec ack
xr eb
Affi hit
(w
Rank applied for INDOS
Available From
Last Drawn Wages

Surname Midddle Name Name

Date of Birth Place of Birth Religion Nationality Pan Card Number

Passport Number Issue Expiry Issued at

CDC Number Issue Expiry Issued at
SID Issue Expiry Issued at

Covid Vaccination Details:

1st Dose Vaccine Date 2nd Dose Vaccine Date Vaccine Manufaturer

Valid Visa's
US Visa C1/D Issued Expiry Place
Any other visa Issued Expiry Place

Contact Details
Present Address Permanent Address

Pin Code Pin Code

Mobile Res. Landline
Email
Nearest Domestic Airport : Nearest Intn'l Airport:

Family details Marital Status

Relationship Surname Name DOB Passport Issue Epxiry Place of Issue

WIFE
Son / Daughter
Son / Daughter
Son / Daughter
Son / Daughter

Next of Kin Relationship

Address

Form # MP 02 REV 00 DATED :01.10.2021

Personal Details Page 1 of 5

 Form # 02

Page 02/05
Academic Qualifications
College /Degree University Year Passed Grade /Percent

Pre Sea Training

Description Insitute Year Passed Grade /Percent

Training Requirements
Certificates STCW Reg Grade Number Issued Validity Issued at
CERTIFICATE OF COMPETANCE (COC)
GMDSS (GOC)
GMDSS ENDORSEMENT
DCE OIL
DCE CHEMICAL
DCE LPG
COP - AB Deck II/5, AB Engine III/5 or Electrician III/7
WATCHKEEPING

STCW Certification STCW Reg Grade Number Issued Validity Issued at

Personal Survival Techniques
Fire Prevention and Fire Fighting
Elementary First Aid
Personal Safety and Social Responsibilities
Security Training for Seafarers with Designated Security Duties
Proficiency in Survival Craft and Rescue Boat
Advanced Fire Fighting
Medical first Aid / Master's Medicare
Oil Tanker Familiarization
Chemical Tanker Familiarization
Gas Tanker Familiarization
Advanced Oil Tanker Safety(TASCO) - Petroleum
Advanced Chem Tanker Safety(CHEMCO)- Chemical
Advanced Gas Tanker Safety(GASCO)- Gas
Ship-Security-Officer
Radar Observer
Radar Simulator
ARPA
Yellow Fever

Other Certification STCW Reg Grade Number Issued Validity Issued at

ECDIS ( IMO 1.27)
Revalidation-Course
Liquid-Cargo-Handling-Simulator
Bridge-Team-Management (BTRM / BRM)
Bridge Simulator
Large Ship Handling Course (VLCC / ULCC)
Inert Gas Systems
Crude Oil Washing
HAZMAT-Course
Ship Maneuvering Simulator
Engine-Room-Simulator
6G Welding Certificate (Fitter / Welder)
Ship Safety Officer
Indian Maritime Legislation course
High Voltage

TYPE SPECIFIC ECDIS (if any, mention below)

Flag Endorsements (Please mention below) STCW Reg Grade Number Issued Validity Issued at

Certification Page 2 of 5
 Form # 02

Form # MP 02 REV 00 DATED :01.10.2021

Certification Page 2 of 5
 Form # 02

Details of Sea Service

Enter your most recent Sea service first Page 03/05

DECK OFFICERS ENGINE OFFICER

COMPANY
RANK VESSEL NAME TYPE FLAG UMS FROM TO REASON FOR S/OFF CARGO CARRIED
(OWNER / OPERATOR)
COP / FRAMO DWT / GRT Engine Type BHP / KW

Form # MP 02 REV 00 DATED : 01.10.2021

Sea Service Page 3 of 5

 Form # 02

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Practical Experience : Have you experience of the following (Please signify thus 'X')
New Building Planned Maintenance System

Steam Turbines Cargo Pumps (a) Computerised (Specify)

Engine Driven Cargo pumps Planned Maintenance System

Cargo Pump type (a) Computerised (Specify)

a) Centrifugal pumps (b) Others

b) Screw pumps Container (specify TEU)

c) FRAMO Pump Reefer container

Cargo Reefer plant Reefer Cargo

Deck crane type Dry dock

a) Thyrister control Major repairs

b) Electrical Major Fire

c) Electro hydraulic Collision

d) Gantry Pollution Incident

Knowledge of ships electrical an

Crude Oil Washing Operations electronic system

Knowledge of vessels automatio

Inert Gas Systems and computerized system

Enumerate the different Nationalities you have sailed :

Officers :
Ratings :

Reason for application : State why you wish to leave your present employment:-

Preference for employment on : Tanker or Dry Cargo or LPG

May we approach your PRESENT employer for Reference ? Tel no. Name :
May we approach your PAST employer for Reference ? Tel no.; Name :
Have you ever had to leave a Company other than voluntarily ?
What date are you available for sea service ?

YES NO Comments
Stability software experience ?
Ship maintenance software experience?
Dangorous Cargo experience?
ECDIS experience?
Stevedore damages experience?
Reefer Cargo experience ?
Dry dock experience during last three years ?
Shipyard delivery team experience ?
UMS vessels, last three years?
Hazardous cargo carriage in last three years ?
Types of Cargo Cranes previously worked with:

(Ship/Location)
Dry Docks
Yard Delivery
Audits / Inspections/Vetting/PSC etc.
Form # MP 02 REV 00 DATED : 01.10.2021

Cargo+Experience Page 4 of 5
 Form # 02

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Deck Officers, :
Cargo Carried

Trading Pattern :

Engineer Officers, Types of

Machinery worked on :

Seafarer Medical history :

Height in Centimetres Weight in Kg's

Boiler Suit Size Safety Shoes Size

Shirt Size Trouser Size (Saloon Staff)

Has the applicant has ever signed off from a vessel on Medical Grounds. If yes, please furnish details. Yes No

Name of Vessel Date signed off Reason / Brief Description of Illness / Injury / Accident

Have you visited the doctor in the last 12 months for any surgery / Illness. If yes, please furnish details Yes No

Date of Illness / Surgery Details of Illness and Treatment received

Please answer the below, by ticking the appropriate box.

Were you ever denied a foreign visa. If yes, please furnish details. Yes No

Are you willing to sail one rank lower ? Yes No

Does the applicant have any history of accidents during his seaservice ? Yes No
If yes, please give details on a separate sheet of paper.

Has the applicant been convicted in a court of Law (Civil / Criminal) ? Yes No
Are any legal proceedings pending against you ?
If yes, please give details on a separate sheet of paper.

Have you had any serious injuries , sicknesses, operations in the last one year, Yes No
If Yes please give details in separate sheet.

References :
# Name of Person Company / Address (No Relatives) Contact numbers & Email Id
1
2

I, hereby declare that all the details given in this application are true. Further, I understand that the company can hold me liable and refuse any claim for treatment,
cost of any other Insured benefits if a complete and true statement of all previous Illnesses is not given.

Signature of Applicant Date and place

FOR OFFICE USE:-

All documents checked/verified with originals. Candidates general health & appearance & spoken english is satisfactory.

Comments: -

Name and Signature of Interviewer / Manning Representative Date and place

Form # MP 02 REV : 00 DATED : 01.10.2021

Declaration Page 5 of 5