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    MSZ Application

    Uploaded by

    Ashok Kumar
    This document is an application form for a maritime position. It requests information about the applicant's personal details, family details, medical history, travel documents, qualifications, certifications, previous sea service experience, and references. The applicant provides information about their name, date of birth, address, nationality, civil status, physical attributes, next of kin, past medical issues, passport details, education history, training, licenses held, courses completed, previous ship experience including vessel names and positions held, cargo carried, and inspection experience. References are also requested. The applicant signs declaring that all information provided is true and correct.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    MSZ Application

    Uploaded by

    Ashok Kumar
    118 views6 pages
    This document is an application form for a maritime position. It requests information about the applicant's personal details, family details, medical history, travel documents, qualifications, certifications, previous sea service experience, and references. The applicant provides information about their name, date of birth, address, nationality, civil status, physical attributes, next of kin, past medical issues, passport details, education history, training, licenses held, courses completed, previous ship experience including vessel names and positions held, cargo carried, and inspection experience. References are also requested. The applicant signs declaring that all information provided is true and correct.

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    © © All Rights Reserved

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    This document is an application form for a maritime position. It requests information about the applicant's personal details, family details, medical history, travel documents, qualifications, certifications, previous sea service experience, and references. The applicant provides information about their name, date of birth, address, nationality, civil status, physical attributes, next of kin, past medical issues, passport details, education history, training, licenses held, courses completed, previous ship experience including vessel names and positions held, cargo carried, and inspection experience. References are also requested. The applicant signs declaring that all information provided is true and correct.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    118 views6 pages

    MSZ Application

    Uploaded by

    Ashok Kumar
    This document is an application form for a maritime position. It requests information about the applicant's personal details, family details, medical history, travel documents, qualifications, certifications, previous sea service experience, and references. The applicant provides information about their name, date of birth, address, nationality, civil status, physical attributes, next of kin, past medical issues, passport details, education history, training, licenses held, courses completed, previous ship experience including vessel names and positions held, cargo carried, and inspection experience. References are also requested. The applicant signs declaring that all information provided is true and correct.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 6

    Application form

    POSITION
    Position Applied for :
    PHOTO
    Are you willing to accept a lower rank? No YES / NO
    Date of Availability: / /

    PERSONAL DETAILS
    1. GENERAL
    Name:
    Date of Birth: Place of Birth: Nationality: INDIAN
    Permanent address:

    Post code:  No.:


    E-Mail address: No.:
    Present address:

    Post code:  No.:


    Nearest Airport
    Civil Status : Single / Married / Separated / Divorced / Widowed. MARRIED
    Height : Cm: Weight : Kg:
    Boiler Suit Size : Shoe Size :
    2. FAMILY DETAILS.
    Full Name of Next of Kin : Relationship :
    Address of Next of Kin :

    Post code:
    Contact telephone numbers:  No.: No.:
    Family Date of
    Name D.O.B PPT. No. D.O.I P.O.I D.O.E ECNR
    Data Anniversary

    Wife

    Child
    (M/F)

    Child
    (M/F)

    Child
    (M/F)

    RPS 01-A Page 1 of 6


    Application form

    `
    3. MEDICAL HISTORY
    (a).Have you ever signed off from a ship due to Medical reasons,(If Yes give details) Yes / No
    Name of the Vessel : Date of Occurrence :

    Brief description of Illness / Injury / Accident :

    (b). Did you suffer or Are you Presently suffering from any disease likely to render you unfit for service at sea or
    Yes / No
    likely to endanger the Health of others on board.
    (c). Are you addicted to alcohol or drugs of any kind? Yes / No
    (d).Have You suffered from Following?
    Malaria Diabetes Epilepsy Nervous Disability Hepatitis of any kind
    Yes / No Yes / No Yes / No Yes / No Yes / No
    (e) Did You ever undergo psychiatric treatment? Yes / No

    TRAVEL DOCUMENTS & VISA


    Passport No: Date of Issue Place of Issue Date of Expiry ECNR Blank Pages

    MUI Membership No. D.O.E.


    U.S.VISA

    Any Other VISA

    ACADEMICS & PROFESSIONAL QUALIFICATIONS


    1. EDUCATIONAL BACKGROUND.
    School / College From To Highest Qualification attained.

    2. PRE SEA TRAINING / APPRENTICE SHIP.


    Name of Institute / College From To Grade / Marks Type of Degree

    CERTIFICATIONS & COURSES

    RPS 01-A Page 2 of 6


    Application form

    `
    1. CDC DETAILS.
    Date of Expiry
    Seaman’s Book Number Date of Issue Place of Issue
    Indian
    Liberian
    Panamanian
    Marshall Islands
    Bahamas
    Vanuatu
    IOM
    Bermuda / Maltese
    Others
    2. INDOS DETAILS.
    INDOS Number
    3. LICENSES.
    Date of
    License Grade Number Date of Issue Place of Issue
    Expiry
    Indian
    U.K.
    Singapore
    Australian
    Liberian
    Panamanian
    Vanuatu
    IOM
    Bermuda
    Others
    4. DETAILS OF COURSES & CERTIFICATES.
    Date of
    Course Type Number Date of Expiry Issued By
    Issue
    Advanced / Basic Fire Fighting
    Proficiency in Survival Craft / Rescue Boat / PST
    Elementary / Medical First Aid / Medicare
    Personal Survival & Social Responsibility (PSSR) as per STCW
    2010
    Radar Observer / ARPA
    Radar Simulator (RANSCO) / ENS
    Ship Manoeuvring Simulator (SMS )
    LCHS ( Operational / Management Level )
    GMDSS / MCC
    Petroleum Tanker Safety (STPOTO)
    Chemical Tanker Safety (CHEMCO)
    Gas Tanker Safety (GASCO)
    Oil Tanker Familiarisation (OTFC)
    Chemical Tanker Familiarisation (CTFC)
    Gas Familiarisation (GTFC)
    Engine Room Simulator (ERS )

    RPS 01-A Page 3 of 6


    Application form

    `
    Hazmat Course
    Bridge Team Management (BTM)
    Revalidation Course
    Yellow Fever
    ISPS / SSO / CSO / STSDS
    Bridge / Engine Resource Management
    Ship Safety Officer
    Refresher Training for PST / PSCRB as per STCW 2010
    Refresher Training for FPFF / AFF as per STCW 2010
    Refresher Training for MFA/ Medicare as per STCW 2010
    Refresher and Updating Training (RUTC) as per STCW 2010
    ECDIS (DG Shipping approved)
    ECDIS Type Specific (JRC/FURUNO/TRANSAS/MARIS)
    Others
    5. DANGEROUS CARGO ENDORSEMENTS
    Grade / Level
    Types Number Date of Issue Place of Issue D.O.E
    I / II
    Oil
    Chemical
    Liquified Gas

    RPS 01-A Page 4 of 6


    Application form

    `
    PREVIOUS SEA SERVICE
    ( Date commencing from last vessel )

    DWT
    Name of Owners / Built UMS Total Reason for
    S.No. Name of Vessel Type Or BHP Engine Type Rank From To
    Manager Year Y/N MM/DD S/Off
    GRT

    RPS 01-A Page 5 of 6


    Application form

    `
    MISCELLANEOUS
    1. DECK OFFICERS.

    Bulk: Type of cargo carried

    Product: Type of cargo carried

    Chemical: Type of cargo carried

    Tanker: Type of pumps

    2. ENGINEERS.
    Automation. (Type)
    Cranes. (Type)
    Grabs. (Type)
    3. ELECTRICAL OFFICERS.
    Automation. (Type)
    NOR Control System. (Type)
    Cranes Hydraulics, Electro Hydraulics. (Type)
    PLC. (Type)
    4. GENERAL TRADING AREA OF VESSELS

    5. OIL MAJOR INSPECTIONS.


    CDI Yes / No
    Port State Control. (Please Specify)
    Others. (Please Specify)
    6. DRY DOCKING EXPERIENCE.

    REFERENCES
    Name of company
    Reference Person
    Address :

     No.
    No.
    DECLARATION
    I hereby affirm that all this information provided by me in this application is true and correct to the best of my knowledge and belief;
    further, that no Certificate of competency or License issued to me has ever been Revoked or Suspended. I also certify that my medical
    history contained above is True and any false statement or undisclosed material information about past illness or injury will disqualify me
    from any employment benefits and claims.

    Date___________ Rank_________________ Signature of Seaman ___________________

    Last Wages Drawn :____________________ Expected Salary : _______________________

    RPS 01-A Page 6 of 6

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