Seashell Marine Services PVT LTD Chennai: Application Form

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APPLICATION FORM

Seashell Marine Services Pvt Ltd


Chennai

Position Applied for : Date of Availabilty

Surname: Name:
PHOTO
Contact Nos : Mob / L L Email:

Date Of Birth Place Of Birth

Nationality : Marital Status :

Address :

Documents Number Place of Issue Date of Issue Date of Expiry

Passport

CDC

INDOS

Yellow Fever

U.S. Visa C1/D

Documents Grade/Level Number Place of Issue Date of Issue Date of Expiry


Nat. Certificate of
Competency (COC)
Oil Endorsement

Chemical Endorsement

Gas Endorsement

COC - Other National

Panama

Liberia

Others

CDC - Other National

Panama

Liberia

GMDSS GOC

GMDSS Endorsement

PSSR

PSCRB/ PST

AFF/ FPFF

MC/ MFA/ EFA

SSO / STSDSD
WATCH KEEPING
CERTIFICATE
Academic Background
Qualification Name of City / Country From To Grade/
Obtained Institution Percentage
10th Std (SSLC) /
Equivalent
12th Std (Hr. Sec) /
Equivalent

Graduate / (Other)

Presea Training
Mates / Masters

FORM : M 01 Page 2 Of 2 Rev -126-May-14 License No-RPSL/CHN / 034


APPLICATION FORM
Seashell Marine Services Pvt Ltd
Chennai

2E/ CE Exams

FORM : M 01 Page 2 Of 2 Rev -126-May-14 License No-RPSL/CHN / 034


APPLICATION FORM
Seashell Marine Services Pvt Ltd
Chennai

Family Details ( Father & Mother / Wife & Children) :

Place of
No. Name Relation D.O.B Sex Passport No Date of Issue Date of Expiry
Issue

1
2
3
4
5
Previous Sea Experience (List service for last five years OR last ten vessels. List recent vessel first)
Type of Deck (Trade & DWT) Period Months / Days
Company's Name VESSEL'S NAME Vessel Engine (Type & BHP) Rank
From To Reason for S/off

Last Employer name, PIC & Contact:

Summary of Sea going Experience


For all Officers: Period served on (yy/mm)
Handymax Panamax Cape Cntr- Feeder Ctnr- +400 P/ Tanker Aframax VLCC LPG/ LNG Chemical Others

For Engineer Officers only : Period served on (yy / mm)

Sulzer B&W MAN Pielstick UEC Doxford Steam UMS CPP Cranes

Nationality of crews sailed with : Declaration by the Applicant


Are you familiar with computer based PMS ? Please specify. I understand that a strict medical examination
including Drug and Alcohol test as per company
Have you been on board vessels during: requirements is a a condition of my employment
and I express my willingness to be examined.
Drydocking: New Construction : Major Conversion
I undertake to provide the company’s medical
officer full details of my previous medical history. I
agree that the decision of the company medical
Incidents of Grounding / Fire / Explosion / Collision / Abandon Ship /
Rescue / officer is final.
Major oil Pollution / Drug Smuggling / Towed or Towing another vessel
I declare that there are no criminal/ police
investigations in progress against me.
Reference -Senior Deck officer - Name & Contact No I confirm that all my travel documents are valid
and in order. I understand that if my travel
Reference - Senior Engineer officer - Name & Contact No Documents become invalid or restricted at any
time during the course of my employment and
cannot be revalidated by me under normal
Reference - Senior Rating - Name & Contact No process, the contract of employment will
terminate and all costs of repatriation will be
Have you ever been involved in a criminal case : If yes on any of the borne by me.
above , give details:
I am /am not presently employed elsewhere.
Medical History & If my application is successful, I will be available
Declaration Height Weight Blood Group
to report at your office on or after:

Do you suffer or have suffered from : Diabetes / High Blood Pressure /


Hepatitis / Epilepay / Nervous Disorders/ Disturbed Vision Or Hearing /
Vertigo If yes, give details :

Are you a habitual user of Drugs / Narcotics / Excessive Alcohol :

Is your MUI/ NUSI membership valid for current year? If Yes, provide
information

Name Of Applicant Rank

Date of Application Signature of the Applicant

FORM : M 01 Page 2 Of 2 Rev -126-May-14 License No-RPSL/CHN / 034

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