You are on page 1of 6

Mideast: 025

FLEET PERSONNEL ADMINISTRATION

SEA STAFF APPLICATION FORM
  

   

PHOTO

APPLICATION FOR POSITION AS

3rd ENGINEER

OTHER POSITION (IF ANY)

1. PERSONAL DETAILS
TITLE MR/MRS/MISS

MR

SEX

MALE

FEMALE

SURNAME

NARE

FIRST NAME

GAURAV

OTHERS NAMES

DATE OF BIRTH

15 FEB 1985

PLACE OF BIRTH

MUMBAI

NATIONALITY

INDIAN

MARITAL STATUS

UNMARRIED

COLOUR OF EYES

BLACK

COLOUR OF HAIR

BLACK

MOTHER’S NAME

VARSHA NARE

FATHER’S NAME

VILAS NARE

173

WEIGHT (KG)

73

MOTHER’S MAIDEN NAME
HEIGHT (CM)

NEAREST INTERNATIONAL AIRPORT:

2. ADDRESS

MUMBAI

ADDRESS (TEMP.) FROM/TO:

NO & STREET

18/803,SAFFRON,REGENCY
ESTATE,KALYAN SHIL ROAD

NO & STREET

CITY

DOMBIVLI EAST

CITY

POST CODE

421203

POST CODE

COUNTRY

INDIA

COUNTRY

TEL. NO.

TEL. NO.

MOBILE

7738821243/7506364819

MOBILE

E-MAIL

gvnare@gmail.com

E-MAIL

FAX

FAX

3. NEXT OF KIN
FULL NAME

VILAS GOVIND NARE

RELATIONSHIP

ADDRESS

18/803,SAFFRON,REGENCY ESTATE,KALYAN SHIL ROAD,THANE DIST DOMBIVLI EAST

Figure 03, Revision 001, Dated 01.05.09
1 of 6

FATHER

PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY CERTIFICATE NAME NUMBER ISSUE DATE EXPIRY DATE ISSUED BY (AUTHORITY) ISSUED AT CL IV INDIA 95Z-12416 08/12/2010 06/02/2020 INDIA MUMBAI DANGEROUS CARGO ENDORSEMENT NUMBER ISSUE DATE EXPIRY DATE PETROLEUM M/0/2/E/12/19856 29/08/2012 31/12/2016 CHEMICAL M/C/1/E/13/23280 05/06/2013 31/12/2016 GAS 9.REGENCY ESTATE. DATE ISS. MOBILE INDIA FAX NO.09 2 of 6 .05. TRAVEL DOCUMENTS TYPE DOCUMENT NO. BANK ACCOUNT INFORMATION BANK NAME AXIS BANK BRANCH DOMBIVLI EAST CITY DOMBIVLI COUNTRY INDIA SORT CODE UTB0000125 BANK ADDRESS ACCOUNT NO BANK SWIFT CODE BANK TEL.JONDHALE VIDYA MANDIR SCHOOL NAME FROM TO 8. Dated 01. EDUCATION SCHOOL NAME FROM 1989 TO 2001 S. Revision 001. LANGUAGES Figure 03.THANE 7. NO 060010100388054 0251-2800671 ACCOUNT OWNER’S NAME GAURAV VILAS NARE ACCOUNT OWNER’S ADDRESS 18/803.DATE EXP.H.USA US C1/D VISA H8817629 26/12/2013 23 /12/2018 USA MUMBAI OTHER VISAS 6.KALYAN SHIL ROAD.Mideast: 025 FLEET PERSONNEL ADMINISTRATION CITY COUNTRY DOMBIVLI TEL. ISS. NO.DOMBIVLI EAST DIST. CHILDREN FULL NAME OF CHILD DATE OF BIRTH SEX M F M F M F M F 5.SAFFRON. BY (AUTHORITY) PASSPORT G 2091699 21/02/2007 20/02/2017 INDIA THANE PLACE OF ISSUE SEAMAN BOOK MUM 148259 13/02/2009 12/02/2019 INDIA MUMBAI OTHER SEAMAN BOOK MH 368136 01/08/2014 21/07/2019 MARSHALL ISLAND VIRGINIA. 9967764819 4.

2013 MEDICAL FIRST AID MEDICAL CARE FAST RESCUE CRAFT G.D.2008 BP MARINE MUMBAI STC/02/13/032 29.2007 OERC ACADEMY MUMBAI BPMA/ENGR-UP/28/2015 07. SAFETY CLOTHING BOILERSUIT SIZE BOOTS SIZE XL 9 12.12. (Management level) RADAR OBSERVATION HAZMAT CHEMICAL TANKER ADVANCE CHEM ANKER GAS TANKER ADVANCE GAS TANFC/KER Figure 03.R.2008 BP MARINE MUMBAI ADVANCE OIL TANKER BPMA/ATOT/453/2011 15.12.02.2011 BP MARINE MUMBAI BPMA/CTFC/894/2008 21.2012 EFA/2825/2007 28.09 3 of 6 MASSA MUMBAI . SAFETY & SOC.01.2020 BP MARINE MUMBAI 27.03. A.2015 BP MARINE MUMBAI PERS.2015 HIMT CHENNAI OIL TANKER BPMA/TFC/829/2008 14.M.2015 26.2015 BP MARINE MUMBAI PROF. HEALTH CERTIFICATES & VACCINATIONS FLAGE STATE ISSUE DATE NUMBER EXPIRY DATE ISSUED BY (AUTHORITY) ISSUED AT INTERNATIONAL LIBERIAN NORWEGIAN PANAMANIAN NAME YELLOW FEVER ISSUE DATE EXPIRY DATE ISSUED BY (AUTHORITY) ISSUED AT 04/12/2018 INDIA MUMBAI 5/12/2008 11.S.A.02.01.05.01.Mideast: 025 FLEET PERSONNEL ADMINISTRATION ENGLISH FLUENT GOOD FAIR POOR GERMAN FLUENT GOOD FAIR POOR FRANCH FLUENT GOOD FAIR POOR SPANISH FLUENT GOOD FAIR POOR ITALIAN FLUENT GOOD FAIR POOR RUSSIAN FLUENT GOOD FAIR POOR MARLIN’S TEST / LEVEL ISSUED DATE RESULT % ISSUED BY (AUTHORITY) ISSUED AT 10.P.S.10. Dated 01. BPMA/ENGR-UP/28/2015 07. MARINE COURSESI COURSE NAME PERSONAL SURVIVAL BASIC FIRE FIGHTING ADV. IN SURVIVAL CRAFT & RESCUE BOATS RPSCRB C/B44/03 31. Revision 001.11. FIRE FIGHTING ELEMENTARY FIRST AID NUMBER SGA/PST/2007-802-10537 ISSUE DATE EXPIRY DATE ISSUED BY (AUTHORITY) ISSUED AT 22-12-2007 21-12-2012 SAGAR GYAN MUMBAI FPFF/8006/2008 12-01-2008 11-01-2013 OERC ACADEMY MUMBAI BPMA/AFF/RF/181/2015 27.11. RESP.

2013 MASSA MUMBAI 12. Revision 001. MARINE COURSES (CONTD……) COURSE NAME ISSUE DATE NUMBER EXPIRY DATE ISSUED BY (AUTHORITY) 13.12.09 4 of 6 ISSUED AT . SHIP HANDLING INTERNAL AUDITORS COURSE STSCSD STS/55/13/1120 20.05.Mideast: 025 FLEET PERSONNEL ADMINISTRATION CRUDE OIL WASHING INERT GAS PLANT ISM CODE SHIP SECURITY OFFICER BRIDGE TEAM MANAGEMENT DP INDUCTION DP SIMULATOR BRIDGE / ENGIINE ROOM RESOURCE MANAGEMENT. Dated 01. SPECIALISED EXPERIENCE TYPE FROM TO COMMENTS NEW BUILDING SPECIALISED PROJECTS SPECIAL TRADES SHORE EXPERIENCE Figure 03.

05.2014 23.dig8shipmanagement.6 Bulk carrier Product Tanker ENGINE TYPE D.2 18.5 3.11.ZHONGJI NO.5 M.T.2013 5.03.T.T.com CONTACT PERSON MR.T.1 20.06.2011 24.T NAVIG8 FAITH 21.04.11.1 M.7 Oil Tanker 7.7 M.12.W.2012 18.2011 09. MORNING GLORY V M.2011 28.EVEREST GRANDE.COMPLETE SEA – SERVICE DETAILS ( LAST VESSELS FIRST ) NAME: GAURAV VILAS NARE COMPANY NAME RANK: RANK SIGNED VESSEL NAME ON AVALIABILITY DATE:07 JULY 2015 ONWARDS 3/E SIGNED OFF PERIOD IN MONTHS TYPE OF VESSEL (eg 4.2) NAVIG8 SHIP MGMT NAVIG8 SHIP MGMT NAVIG8 SHIP MGMT GENMARCO SOVEREIGN SAFESHIP FIVE STAR SHIPPING 3/E 3/E 4/E 4/E 4/E 5/E M.2013 05. 022 6606 0000 FAX/E-MAIL Fleet@nave.03.T.01.05.2014 05.T. ( ENGINEERS ONLY) NAVIG8 SHP MGMT ADDRESS B-210.2014 6.10.MAHA GAYATRI 20.ZHONGJI NO.UNION PRIDE M.05.2009 Product Tanker Oil Chem Tanker Oil Chem Tanker 5.AJIT KESARKODI DATE KW MAN B&W 11610 8530 WARTSILLA 12730 9360 WARTSILLA 12730 9360 MAN B&W 13510 9930 HANSHIN 4500 3300 SULZER 11550 8490 REFERENCE CONTACT DETAILS COMPANY NAME BHP SIGNATURE .ANDHERI EAST PHONE NO.2009 01.2014 1.

Signature .. ……………………………………. 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.No Officer Application Form (For Official Use) Medical History Have you ever signed off from a ship due to medical reasons? (If yes give details) *yes/no Date of occurrence (dd-mmm-yyyy) Name of Vessel Brief Description Of illness/Injury/Accident Details Have you ever suffered from any ailment or disease in the past that is likely to render you unfit for sea service or likely to endanger the health /well being of others onboard? (If Yes give details) *Yes/No Details Do you have any bodily defects or deficiencies? (If Yes give details) *Yes/No Details Are you currently suffering from any ailment or disease that is likely to render you unfit for sea service or likely to endanger the healthy /well being of others onboard? (If Yes give details) *Yes/No Details Are you addicted to alcohol or drug of any kind? (If Yes give details) *Yes/No Details Are you suffering from an ailment that requires you to be on a long -term treatment/medication? (If Yes give details) *Yes/No Details Have you ever deported or banned from entering any country? (If Yes give details) *Yes/No Details Have you ever been convicted of a criminal or drug offence or have any pending offences? (If Yes give details) *Yes/No Details Do you have any obligations towards your current/previous employers? (If Yes give details) *Yes/No I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge and belief. dd-mmm-yyyy (Format) ……………………………………. further..Ref .

Related Interests