20 Science Park Road
#02-34/36 TeleTech Park
Singapore
Tel: 117674
+65 6500 4040
Fax: +65
APPLICATION FORM - DETAILED 6500 4050
www.goodwoodship.com
PART - A : PERSONAL INFORMATION AND REFERENCE
Rank Applied :
First Name :
Middle Name :
Kindly paste a
Family Name : photograph :
Birth Date : Size
Place Of Birth :
35 mm X 45 mm
Country Of Birth :
Nationality :
Gender - Male / Female :
Nearest Airport International Domestic
Marital Status : Available date of Joining :
Next Of Kin Name : : Signature :
Next Of Kin - Relationship :
Next Of Kin - Address :
Phone Mobile
Next Of Kin - Contact Details :
E-mail
Present Address :
Phone Mobile
Contact Details of Officer:
E-mail
Permanent Address :
CHILDREN PARTICULARS
Date Of Place Of Date Of
Names Relationship Place Of Birth Passport No. ECNR Validity
Birth Issue Expiry
TRAVEL DOCUMENTS
: Passport Details : : Seaman Book (CDC) Details :
Number : Number :
Place Of Issue : Place Of Issue :
Date Of Issue : Date Of Issue:
Date Of Expiry : Date Of Expiry :
Visa Details Number :
U.S. Visa Singapore Visa Place Of Issue :
Type Type Date Of Issue:
Place Issued : Place Issued : Date Of Expiry :
Date Issued : Date Issued :
Date Of Expiry : Date Of Expiry : INDOS No.
08.73.05.001.02
Indian liaison office: Goodwood Marine Services Pvt Ltd.
Unit 905, 9th Floor, Hubtown Solaris, N. S. Phadke Marg, Andheri (E), Mumbai 400069 1 of 7
Tel:+91-22-67200400, Fax:+91-22-67200404, E-mail: [email protected]
LICENCES & DOCUMENTATION DETAILS
C.O.C. -1 National C.O.C. - 2 C.O.C. - 3
Licence Grade : Licence Grade : Licence Grade :
Licence Number : Licence Number : Licence Number :
Date Of Issue : Date Of Issue : Date Of Issue :
Date Of Expiry : Date Of Expiry : Date Of Expiry :
Place Of Issue : Place Of Issue : Place Of Issue :
Country Of Issued : Country Of Issued : Country Of Issued :
MANDATORY & STCW COURSES DETAILS
Date Of Date Of
Names and Description Number Place Of Issue
Issue Expiry
Personal Survival Techniques
P.S.C.R.B.
Basis Fire-Fighting
Advanced Fire-Fighting
Elementary First-Aid
Medical First-Aid
Ship Captain's Medicare
Medical Care
P. S. S. R.
Tanker familiarisation (Petroleum)
Tanker familiarisation (Chemical)
Tanker familiarisation (Gas / LPG)
Specialised Tanker Safety (Petroleum)
Specialised Tanker Safety (Chemical)
Specialised Tanker Safety (Gas / LPG)
Dangerous Cargo Endorsement (Petroleum) - Level 1
Dangerous Cargo Endorsement (Chemical) - Level 1
Dangerous Cargo Endorsement (Gas / LPG) - Level 1
Dangerous Cargo Endorsement (Petroleum) - Level 2
Dangerous Cargo Endorsement (Chemical) - Level 2
Dangerous Cargo Endorsement (Gas / LPG) - Level 2
G.M.D.S.S. LICENCE WITH ENDORSEMENT
Radar Observers course (ROC)
Automatic Radar Plotting Aids (ARPA)
Radar Simulator / ENS
Engine Room Simulator
Ship Handling Simulator
Liquid Cargo Handling Simulator (2.5 Days)
Liquid Cargo Handling Simulator (5.0 Days)
E. C. D. I. S. (Generic - 5 Days)
ECDIS (Type Specific)
■ TRANSAS
■ JRC
■ FURUNO
■ OTHERS (Specify)
Ship Manoeuvring & Bridge Team Work
BTM / BTRM / ERM
Ship Security Officer (S.S.O.)
STSDS
Yellow Fever Vaccination
MRM
08.73.05.001.02
Indian liaison office: Goodwood Marine Services Pvt Ltd.
Unit 905, 9th Floor, Hubtown Solaris, N. S. Phadke Marg, Andheri (E), Mumbai 400069 2 of 7
Tel:+91-22-67200400, Fax:+91-22-67200404, E-mail: [email protected]
NON-STCW & IN-HOUSE TRAINING / COURSES DETAILS
Date Of Date Of
Names and Description Number Place Of Issue
Issue Expiry
Oil Pollution Act - 90 (OPA-90) with VRP
Planned Maintenance System Familiarization (PMS)
High Pressure Hydraulics Cargo Pump System (HPS /
FRAMO)
Internal Auditor's Course
Energy Conservation Course
Risk Assessment / Management Course
Accident Investigation / Prevention Course
Human Behaviour & Relationship Course
On Board Commercial Management Course
Inspection / Surveys / Vetting Familiarisation
Vessel Resource Management Course
Engine Room Team Management Course
Shipboard Safety Officer
Commercial Awareness Course
Training Of Trainers Course
HAZMAT Course
MARLIN'S English test
MARPOL
Automation
Marine Electric Workshop
STS Operation
Wartsila-RT-Flex
B&W - Main Engine
EDUCATIONAL BACKGROUND & TRAINING
Name Of School / Type Of Qualification -- Diploma / Degree /
Curriculum City / Country From To
College Certificates Received
Primary School
Secondary School
Pre-Sea Training
Nav. College - 1
Nav. College - 2
Nav. College - 3
Any Remarks :
08.73.05.001.02
Indian liaison office: Goodwood Marine Services Pvt Ltd.
Unit 905, 9th Floor, Hubtown Solaris, N. S. Phadke Marg, Andheri (E), Mumbai 400069 3 of 7
Tel:+91-22-67200400, Fax:+91-22-67200404, E-mail: [email protected]
PREVIOUS SEA EXPERIENCE (At least 10 Vessels details --- To commence with Last Vessel)
Type Mandatory for
Engineers M
(OBO/
Manning o D
VLCC/
Agents / n a
Sr. Vessel Name Tanker/ Flag DWT Rank From To
Owners t y
Chemica
Engine Type BHP Name h s
l/Gas
s
Etc.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
ACTUAL TIME SERVED IN MONTHS
TANKERS Contai General Bulk
RANK VLCC OBO Ro Ro Others
Crude Product Chemical LPG LNG ner Cargo Carrier
M D M D M D M D M D M D M D M D M D M D M D M D
Master
Chief Officer
Second Officer
Third Officer
Deck Cadet
Chief Engineer
Second Engineer
Third Engineer
Fourth Engineer
Jr. Eng./Eng Cdt
El. Officer
Other Rank
: DURING YOUR TENURE ON VARIOUS TYPE OF TANKERS, KINDLY LIST THE TYPE OF CARGOES CARRIED :
08.73.05.001.02
Indian liaison office: Goodwood Marine Services Pvt Ltd.
Unit 905, 9th Floor, Hubtown Solaris, N. S. Phadke Marg, Andheri (E), Mumbai 400069 4 of 7
Tel:+91-22-67200400, Fax:+91-22-67200404, E-mail: [email protected]
REFERENCES & MISCELLANEOUS INFORMATION
PRESENT OR LAST COMPANY (1) PRESENT OR LAST COMPANY (2)
Name Of Company Name Of Company
Address Of Company Address Of Company
Telephone Number Telephone Number
Person to Contact Person to Contact
Designation / Position Designation / Position
Reason for Leaving Reason for Leaving
PHYSICAL / HEALTH DECLARATION
Height (Cms) Weight (Kgs)
Hair Colour Eyes Colour
BMI
Identification Mark On Body (If Any)
Condition Yes No Condition Yes No
Eye / Vision Problem Rheumatic Or Joint Trouble
High Blood Pressure Chronic Back Pain OR Back Problem
Heart / Vascular Disease Sleep Problem
Heart Surgery Any Operation / Surgery
Varicos Vains Epilepsy / Seizures
Asthama / Bronchitis Dizziness / Fainting
Tuberculosis / Other Lung Disease Loss Of Consciousness
Blood Disorder Mental Disorder
Diabetes Mellitus Depression
Thyroid Problem Attempted Suicide
Digestive Disorder Loss Of Memory
Kidney / Bladder Problem Balance Problem
Skin Problem Severe Headaches
Allergies Ear / Nose / Throat Problems
Infectious / Contagious Disease Restricted Mobility
Hernia Back Problems
Genital Disorders Amputation
Cancer / Or Tumor Fractures / Dislocation
If any of the above questions were answered "YES", Then please provide details :
08.73.05.001.02
Indian liaison office: Goodwood Marine Services Pvt Ltd.
Unit 905, 9th Floor, Hubtown Solaris, N. S. Phadke Marg, Andheri (E), Mumbai 400069 5 of 7
Tel:+91-22-67200400, Fax:+91-22-67200404, E-mail: [email protected]
: ADDITIONAL QUESTIONS ON HEALTH :
Have you ever been signed-off as sick or repatriated from a vessel ?.
Have you ever been hospitalised ?.
Have you ever been declared unfit for sea-service duty ?.
Has your medical certificate ever been restricted or revoked ?.
Are you aware that you have any medical problems, diseases or illness ?.
Are there any aspects of your health which may affect your on board work ?
Do you feel healthy and fit to perform the duties of your designated position / occupation ?
Have you had a problem with drug or alcohol abuse ?
Do you have any injury or injuries causing persistent incapacity, pain or trouble ?
Are you allergic to any medication or particular item ?
Are you taking any non-prescribed or prescribed medication ?
If any of the above questions were answered "YES", Then please provide details :
ANY PREVIOUS SHORE EXPERIENCE (e.g. Dry Docking, Ship Yard Take Over, Layup, Demolition)
I hereby certify / declare that the above details are correct to the best of my knowledge.
Signature of Applicant Date
08.73.05.001.02
Indian liaison office: Goodwood Marine Services Pvt Ltd.
Unit 905, 9th Floor, Hubtown Solaris, N. S. Phadke Marg, Andheri (E), Mumbai 400069 6 of 7
Tel:+91-22-67200400, Fax:+91-22-67200404, E-mail: [email protected]
OFFICE USE ONLY
: COMPETENCE EVALUATION OF SEAFARER :
English Proficiency Exceeds Meets Below
Competence (CES Test) Exceeds Meets Below
Has the candidate's COC YES NO
is verified from issuance
authorities
: INTERVIEW SELECTION :
Interviewed By
Designation
Date of Interview
Suitable for Employment YES NO
: REFERENCE CHECK FROM PRESENT OR PREVIOUS EMPLOYER :
Reference Check Made By :
Date of Reference Check :
Name Of Person giving reference:
Position / Designation :
Above Below RECOMMENDED
Particulars Excellent Average
Average Average FOR EMPLOYMENT
Ability YES
Health / Medical Condition
Personal Conduct
Any Alcohol / Drug Problem
Performance
Interpersonal Relations NO
Attitude Towards Work
Teamwork / Leadership Qualities
Is The Qualification in Compliance
Approved for Re-employment
Training Needs: To be completed
by date:
Name Of Signature Of
DATE
Interviewer Interviewer
08.73.05.001.02
Indian liaison office: Goodwood Marine Services Pvt Ltd.
Unit 905, 9th Floor, Hubtown Solaris, N. S. Phadke Marg, Andheri (E), Mumbai 400069 7 of 7
Tel:+91-22-67200400, Fax:+91-22-67200404, E-mail: [email protected]
