M.T.

MShipManagement(India)PrivateLimited
SolitaireCorporateParkUnit#761,BldgNo.7,6thFloorAndheriGhatkoparLinkRoad,
Andheri(East)Mumbai400093.INDIA(RPSLNumber:MUM205)
Tel:(91)2242003200to299,Fax:(91)2242003210
Email:
mumbai@mtmshipmanagement.com

www.mtmshipmanagement,com

APPLICATIONFORM/PERSONALDATAUPDATEFORM
RANKAPPLIED

3rdofficer

07NL0586

INDOSNUMBER

DATEOFAPPLICATION

18/02/2015

DATEOFAVAILABILITY

anytime

1.PERSONALDETAILS
SURMAMEFIRSTNAMEMIDDLENAME

NAME

KUMAR

DateofBirth

15/12/1987

Permanent
Address

INDIRACOLONY,PLOTNO1019,
RANCHIROADMARAR,
RAMGARH829117,JHARKHAND,INDIA

PlaceofBirth

MUKESH

JAMSHEDPUR

Nationality

PresentAddress

INDIAN

SAMEASPERMANENTADDRESS

City&PinCode:829117

City&PinCode:RAMGARH829117

Telephone:09973061565

Telephone:

Email1:mukeshkumar0657@gmail.com

Email2:

2.NEXTOFKIN/FAMILYPARTICULARS

NAME/RELATION

USHADEVI

ADDRESS

INDIRACOLONY,PLOTNO1019,RANCHIROADMARAR,RAMGARH829117,JHARKHAND,INDIA

NAME

D.O.B

PP/NO.

ISSUED/VALIDITY

WIFE:

CHILD(M/F):

CHILD(M/F):

3.PASSPORTDETAILS

PASSPORT
USC1/DVISA
ECNR

NUMBER

PLACEOFISSUE

DATEOFISSUE

DATEOFEXPIRY

G0116709

RANCHI

17/10/2006

16/10/2016

4.CONTINUOUSDISCHARGECERTIFICATES(S)

CDC

NUMBER

PLACEOFISSUE

DATEOFISSUE

DATEOFEXPIRY

INDIAN

MUM145018

MUMBAI

09/10/2007

08/10/2017

LIBERIAN

OTHERS

5.ACADEMICQUALIFICATIONS
Grade/DegreeFrom(Year)To(Year)

SCHOOL

PROJECTHIGHSCHOOL

67%

2002

COLLEGE

SIRJJGHANDHI
MEMORIALCOLLEGE
IMI

63%

2003

2005

PASS

2005

2007

PRESEATRAINING
INSTITUTE

6.LICENCE/CERTIFICATEOFCOMPETENCY

Grade

Number

Dateof
Expiry

DateofIssue

Dateof
Revalidation

STCW95

YESNO

INDIAN

UK/AUS

LIBERIAN

ITALIAN

HONGKONG

SINGAPORE

FG

D30004520

08/10/2012

31/12/2016

OTHERS

7.STCWANDOTHERCERTIFICATES

STCWCourses

CertificateNo. DateofIssue DateofExpiry

Placeof
Issue

IssuingAuthority/
INSTITUTE

PSSR

PSSR1111

17/05/2007

EFA/MFA/MEDICARE
(FirstAid)
PST/PSCRB
(Survival)

BPMA/M/196/
2011
BPMA/PSCRB
/469/2011

05/03/2011

GREATER
NOIDA
MUMBAI

IMI

18/03/2011

MUMBAI

FP&FF/AFF
(FirstFighting)
ROC

AFF708

12/03/2011

MUMBAI

BPMARINE
ACADEMY
BP
MARINEACADEMY

IMU

ARPA

GMDSS

12/10/2011

11/10/2016

SINGAPORE

SMA

GMDSSEND

SINGHH
03158

REFRESHER&UPDATING

RANSCO/NARAS

S0MS/NAVCONTROL

W/KCERT.FORRATINGS

SIMULATORTRAINING

ENS/025/2011

15/07/2011

SMA

ENGINESIMULATOR

SINGAPORE

BTM

ECDIS

C/161/06

05/11/2012

KOLKATA

ICENAVIGATION

SENSEA
MARITIME
ACADEMY

BRM/ERM/VRM

BT09197

06/08/2009

DELHI

ARI

TANKERCOURSES

TF0916

15/10/2007

GN

IMI

TASCO/TANKERFAM.

CHEMCO/CHEMFAM.

GASCO/GASFAM.

DCEPETROLEUM

DCECHEMICAL

DCEGAS

LIQUIDCARGOSIM

OTHERCOURSES

SafetyOfficersCert/ISPS(SOC)

HAZMAT

SSO

COOKERYCOURSE

WELDING2G,3G,6G

8.SEAEXPERIENCE
:(
Mostrecentfirst)
VESSEL
COMPANY

MAINENGINE

NAME

TYPE

DWT

GRT

YEAR
BUILT

RANK

BWSHIPPING

BERGEACONCAGUA

BULK

388138
MT

196199

3RD

BWSHIPPING

BERGEACOCAGUA

BULK

388138
MT

196199

4TH

BWSHIPPING

BERGESTAHL

BULK

331196
MT

175720

1986

4TH

BWSHIPPING

BWKIBO

BULK

289885
MT

155823

DCDT

BWSHIPPING

BWBUREYA

BULK

153506

MA
KE
B
&W

B
&W

B
&W

MODEL

BHP

2761
0

31920

DCT

AnyMajorIncidence/Observation/SpecialExperienceforreporting:

9.REFERENCES
(Pleasegivetworeferences/companieswhomwecanaskaboutyourseagoingexperience)

Name

Company/
Designation

Telephone/Contact Name
No.

Company/
Designation

REMARKS

9A.REF.CHECK

YES/NO

10.HOWDIDYOUCOMETOKNOWABOUTUS?
(Pleaseticktheappropriatemedium)

A Companypresentation/seminar

C Marinemagazineadvertisement

D Newspaperadvertisement

DirectMailfromCompany

G Other(PleaseSpecify)

BYFRIEND

11.DECLARATION
Ideclarethattheinformationgivenbymeinfillingupthisfromtothebestofmyknowledgearetrueandcomplete.Ialsodeclarethat
thedocumentssubmittedto
MTMSHIPMANAGEMENT(INDIA)PRIVATELIMITED.
aregenuine,givenandsignedbythe
personswhosenamesappearonthem.Anyfalsedeclarationmayrendermeliableforterminationordismissal

Date
:

18/02/2015
SIGNATUREOFAPPLICANT
:

12.SPACEFOROFFICIALUSE

ForwardedtoMTMSingapore

MTMSingaporeACCEPTANCEDETAILS

ACCEPTED

YES

Assessment:Grade

Personality

Attitude

TechnicalKnowledge

EnglishKnowledge

OverAssessment

NO

REF.

ApplicationStatus:

Date:

Grade:AExcellent,BGood,CSatisfactory,
DAverage.EPoor

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Date:

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