PERSONAL INFORMATION 1 1. Surnames 2.

Given Names (If Your Passport Does Not Include A Given Name, Please Enter FNU In Given Names.) 3. Full Name In Native Alphabet 4. Have you ever used other names (i.e maiden, religious, professional, alias, etc.,)? 5. Sex 6. Marital Status NO YES MALE MARRIED SINGLE 7. Date Of Birth (DD-MMM-YYYY) 8. City Of Birth 9. State/ Province Of Birth 10. Country Of Birth INDIA PERSONAL INFORMATION 2 11. Nationality 12. Do You Hold/Have You Held Nationality Other than the one you have indicated above? 13. National Identification Number 14. Us Social Security Number 15. Us Taxpayer Id Number ADDRESS AND PHONE INFORMATION 16. Home Address a. Street Address b. Street Address2 c. City d. State / Province e. Postal Zone / Zip Code f. Country INDIA

17. Mailing address: is your mailing the same as your home address? NO a. Street address b. Street address2 c. City d. State / province e. Postal zone / zip code f. Country 405 4FLR CHALLMALL BUILDING NO11 THEYAGARAYA ROAD T NAGAR CHENNAI TAMILNADU 600017 INDIA

18. Home phone number 19. Work phone number 20. Work fax number 21. Mobile/ cell phone number 22. Email address PASSPORT INFORMATION 23. Passport number 24. Passport book number 25. Country / authority that issued passport 26. Where was the passport issued a. City b. State c. Country d. Issuance date(DD/MMM/YYYY) e. Expiration date (DD/MMM/YYYY) 27. Have you ever lost a passport or had one stolen? NO YES INDIA INDIA 91-44-42929300 91-44-42929301

TRAVEL INFORMATION 28. 29. 30. 31. 32. 33. 34. Are you the principal applicant Purpose of trip to us Other specify Have you made specific travel plans? Intended date of arrival Intended length of stay in U.S. Address where you will stay in the U.S A. Street address CO NORTON LILLY INTERNATIONAL YES OTHER CREWMEMBER IN TRANSIT TO JOIN VESSEL No

7 Days

B. Street address2 C. City D. State / province E. Postal zone / zip code 35. Person/ entity paying for your trip 36. Name of the organization paying for trip 37. Telephone number 38. Relationship to you

ONE ST LOUIS CENTRE MOBILE LOUISIANA 36602 COMPANY/ORGANIZATION MITSUI OSK LINES MARITIME INDIA PVT LTD., 91-44-42929300 EMPLOYER

39. Is the address of the party paying For your YES trip the same as your home Or mailing address TRAVEL COMPANIONS INFORMATION 40. Are There Other Persons Traveling With You NO

PREVIOUS U.S TRAVEL INFORMATION 41. Have you even been in the U.S.? Provide information on your last 5 U.S. visits: a. Date of arrival Length of stay b. Date of arrival Length of stay 42. Do you or did you ever hold a U.S drivers license? 43. Have you ever been issued a U.S. visa YES NO YES NO Date of last visa was issued Visa number 44. Are you applying for the same type of visa? 45. Are you applying in the same country where the visa above was issued and is this country your principal country of residence? 46. Have you been ten printed 47. Has your us visa ever been lost or stolen? YES YES

NO NO YES

48. Has your us visa ever been cancelled or revoked?

NO YES

49. Have you even been refused a us visa, been NO refused admission to the united states, or YES withdrawn your application for admission at the point of entry? U S POINT OF CONTACT INFORMATION 50. Contact person Surnames Given names 51. Organization name in the U.S. 52. Relationship to you 53. Address and phone number of point of contact street address City State Zip code Phone number E mail address FAMILY INFORMATION: 54. Fathers full name and date of birth Surnames Given names Date of birth Is your father in the U.S? YES NO 55. Mothers full name and date of birth Surnames Given names Date of birth Is your father in the U.S? YES NO 56. Do you have any immediate relatives, not including parents in the United States? 57. Do you have any other relatives in the united states? NO YES NO YES ONE ST LOUIS CENTRE MOBLE LOUISIANA 36602 251- 219-3270 CO NORTON LILLY INTERNATIONAL BUSINESS ASSOCIATE

58. Spouses full name and date of birth Surnames Given names Date of birth Nationality City of Birth Country of Birth Address SAME AS MAILING ADDRESS WORK/ EDUCATION / TRAINING INFORMATION 59. Primary occupation 60. Specify other 61. Present employer or school name a. Street address b. Street address2 c. City d. State / province e. Postal zone / zip code f. Country OTHER SHIPPING MITSUI OSK LINES MARITIME INDIA PVT LTD 405 4FLR CHALLMALL BUILDING NO11 THEYAGARAYA ROAD T NAGAR CHENNAI TAMILNADU 600017 INDIA Rs.

62. Month salary in local currency 63. Briefly describe your duties 64. Previously employed Employer name Employer address City State Postal code

Country

Telephone number

Job title

Supervis ors name

Emp. Date from

Emp. Date to

65. Have you attended any educational institutions other than elementary schools? Name of Institution Address of Inst. City State Postal code
Country

Course Study TENTH

Date OF
ATTENDANCE

Date OF
ATTENDANCE

From

To

PLUS TWO

BE / BSC

PRE SEA

66. Do you belong to a clan or tribe

No Yes

67. Have you traveled to any countries within the last five years? 68. Have you belonged to, contributed to, or worked for No any professional, social, or charitable organization? Yes 69. Do you have any specialized skills or training, No including firearms, explosives, nuclear, biological, or Yes chemical experience? 70. Have you ever served in the military? No Yes 71. Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization? No Yes

SECURITY AND BACKGROUND INFORMATION

72. Do you have a communicable disease of public No health significance such as tuberculosis (TB)? Yes 73. Do you have a mental or physical disorder that poses No or is likely to pose a threat to the safety or welfare of Yes yourself or others? 74. Are you or have you ever been a drug abuser or No addict? Yes 75. Have you ever been arrested or convicted for any No offense or crime, even though subject of a pardon, Yes amnesty, or other similar action?

76. Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?

No Yes

77. Are you coming to the United States to engage in No prostitution or unlawful commercialized vice or have Yes you been engaged in prostitution or procuring prostitutes within the past 10 years? 78. Have you ever been involved in, or do you seek to No engage in, money laundering? Yes 79. Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? 80. Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? 81. Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations? 82. Are you a member or representative of a terrorist organization? No Yes No Yes No Yes No Yes

83. Have you ever ordered, incited, committed, assisted, No or otherwise participated in genocide? Yes 84. Have you ever committed, ordered, incited, assisted, No or otherwise participated in torture? Yes 85. Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence? 86. Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom? 87. Have you ever been the subject of a removal or deportation hearing? 88. Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or any other United States immigration benefit by fraud or willful misrepresentation or other unlawful means? 89. Have you ever been unlawfully present, overstayed the amount of time granted by an immigration official or otherwise violated the terms of a U.S. visa? 90. Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal custody by a U.S. court? No Yes No Yes No Yes No Yes No Yes No Yes

91. Have you voted in the United States in violation of No any law or regulation? Yes 92. Have you ever renounced United States citizenship No for the purpose of avoiding taxation? Yes 93. Have you attended a public elementary school on student (F) status or a public secondary school after November 30, 1996 without reimbursing the school? CREW VISA INFORMATION 94. Specific job title aboard aircraft or vessel: 95. Name of company that owns the aircraft or vessel you MITSUI OSK LINES MARITIME INDIA PVT LTD will be working on: 96. Company telephone number: 91-44-42929300 97. Did you acquire your position using a recruiting/manning/crewing agency? a. Agency Name: b. Surname c. Given name d. Street address e. Street address2 f. City YES MITSUI OSK LINES MARITIME INDIA PVT LTD SRINIVASAN SATHYANARYANAN 405 4FLR CHALLMALL BUILDING NO11 THEYAGARAYA ROAD T NAGAR CHENNAI TAMILNADU 600017 INDIA 91-44-42929300 No Yes

g. State / province h. Postal zone / zip code i. j. Country Telephone number

98. Are you serving aboard a seagoing ship or vessel? a. Seagoing Ship/Vessel Name: b. Seagoing Ship/Vessel Identification Number: 99. LOCATION INFORMATION a. Current Location: 100. Preparer of Application a. Did anyone assist you in filling out this application? NO