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MTM Application Form-2024

Mtm company form

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Bhanu Shankar Panda
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41 views5 pages

MTM Application Form-2024

Mtm company form

Uploaded by

Bhanu Shankar Panda
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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M.T.

M Ship Management (India) Private Limited


4th Floor, Gala Impecca, Next to Courtyard by Marriot, Andheri-Kurla Road,
Andheri (East), Mumbai-400059.RPSL: MUM-205 - Validity 21.12.2021
Email: - [email protected] www.mtmshipmanagement,com

APPLICATION FORM / PERSONAL DATA UPDATE


FORM
RANK APPLIED DATE OF APPLICATION

INDOS NUMBER DATE OF AVAILABILITY

1. PERSONAL DETAILS SURNAME FIRST NAME MIDDLE NAME

NAME

DOB NATIONALITY
Permanent
Present Address
Address
City & Pin Code City & Pin Code
TELEPHONE MOBILE
EMAIL ID EMAIL ID
HEIGHT (CMS): WEIGHT(KG): WAIST: SHOE SIZE: BLOOD GROUP: LAST DRAWN WAGES:

2. NEXT OF KIN / FAMILY PARTICULARS


NAME / RELATION
ADDRESS

NAME DOB PP/NO. ISSUED/VALIDITY


WIFE:
CHILD (M/F):
CHILD (M/F):

3. PASSPORT DETAILS
NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY
PASSPORT
US C1/D VISA
S SCHENGEN VISA
OTHER VISA

4. CONTINUOUS DISCHARGE CERTIFICATES(S)


CDC NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY
INDIAN
PANAMA
LIBERIA
MARSHALL

5. ACADEMIC QUALIFICATIONS Grade / Degree From (Year) To (Year)

SCHOOL
COLLEGE
PRE- SEA TRAINING
INSTITUTE

6. LICENCE / CERTIFICATE OF COMPETENCY


Grade Number Date of Issue Date of Date of STCW 95
Expiry Revalidation YES NO
INDIAN
UK
PANAMA
HONGKONG
SINGAPORE
LIBERIA
MARSHALL

7. STCW AND OTHER CERTIFICATES

STCW Courses Certificate No. Date of Issue Date of Expiry INSTITUTE

FP & FF / AFF
EFA/MFA/MEDICARE
PSSR
PST/ PSCRB
ROC
ARPA
RANSCO / NARAS
REFRESHER & UPDATING (RUT)
BRM/ ERM / VRM/ MRM
BTM
ECDIS (1.27)
FLAG ECDIS
SSO
SSO FLAG
SIMULATOR TRAINING
ENGINE SIMULATOR (ERM)
SAFETY OFFICER COURSE
HAZMAT
ICE NAVIGATION
WELDING 2G,3G,6G
COOKERY COURSE
Seafarers Identification Document (SID)
TANKER COURSES
TASCO / TANKER FAM.
CHEMCO/ CHEM FAM.
GASCO/ GAS FAM.
LIQUID CARGO SIM
AUGUMATION
COMBINED OILCHEMICAL
7A GMDSS & DANGEROUS CARGO ENDORSMENT / WK CERTIFICATE & COP.

LEVEL 1 / 2
STCW Courses Certificate No. Date of Issue Date of Expiry INSTITUTE

GMDSS BOOKLET
GMDSS ENDORSMENT
FLAG GMDSS
OIL ENDORSMENT
FLAG OIL ENDORSMENT
CHEMICAL ENDORSMENT
FLAG CHEMICAL ENDORSMENT
LPG ENDORSMENT
FLAG LPG ENDORSMENT
WK CERTIFICATE
COP FOR CREW
CHCOOK COC
8. SEA EXPERIENCE: (Most recent first)
REASON
VESSEL MAIN ENGINE PERIOD FOR
SIGN-
COMPANY OFF
BWTS YEAR IGG /
NAME TYPE DWT GRT Make / Type RANK MAKE MODEL BHP FROM TO M/D
BUILT N2GEN

Any Major Incidence / Observation / Special Experience for reporting: None


9. REFERENCES (Please give two references/companies whom we can ask about your seagoing experience)
Name Company /Designation CONTACT NO Name

REMARKS

9A. REF. CHECK


YES / NO

10. HOW DID YOU COME TO KNOW ABOUT US? (Please tick the appropriate medium) 

A Company presentation/seminar B C Marine magazine advertisement

D Newspaper advertisement E F Direct Mail from Company

G Other (Please Specify)

11. DECLARATION
I declare that the information given by me in filling up this from to the best of my knowledge are true and complete. I also declare
that the documents submitted to MTM SHIP MANAGEMENT (INDIA) PRIVATE LIMITED. are genuine, given and signed by
the persons whose names appear on them. Any false declaration may render me liable for termination or dismissal

Date: SIGNATURE OF APPLICANT:

12. SPACE FOR OFFICIAL USE


Assessment: Grade Application Status: Date :

Personality Forwarded to MTM Singapore


Attitude MTM Singapore ACCEPTANCE DETAILS
Technical Knowledge ACCEPTED YES NO
English Knowledge REF.

Over Assessment

Grade: A – Excellent, B-Good, C-Satisfactory,


D – Average. E- Poor

Interviewed by Date:

INTERVIEWER’S REMARKS:

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