NAVIG8 SHIP MANAGEMENT

B-210, 2nd Floor, EVEREST GRANDE, Shanti Nagar, Mahakali Caves Road, Andheri (East), Mumbai - 400 093, INDIA RPSL NO. 141 For Office use only
Employment Code

Ref. N8SM/2010Rank Approved Date of Readiness

Rank Applied For

Surname

Self Name

Father's / Middle Name

Date of Birth

Place of Birth

Religion

Documents Passport Indian CDC Nationality Valid Visas US Visa C1/D

Number

Issue Date

Expiry Date

Place of Issue

Nearest Airport Number Issue Date Expiry (Year) Place of Issue

Contact Details
Present Address Permanent Address

PIN Code Telephone No. E-Mail Address Mobile No. Telephone No. E-Mail Address

PIN Code Mobile No.

Family Details
Relationship Surname Name

Marital Status Date of Birth

Married / Bachelor Passport No. Issue Date Expiry Date Place of Issue

Next of Kin (Name) Address

Relationship

Telephone No.

Mobile No.

E-Mail Address

Page 1 of 4

NAVIG8 SHIP MANAGEMENT

B-210, 2nd Floor, EVEREST GRANDE, Shanti Nagar, Mahakali Caves Road, Andheri (East), Mumbai - 400 093, INDIA
Certificates
Certificate of Competency Endorsement to Certificate of Competency GMDSS (GOC) Watchkeeping Certificate Tanker Endorsement (Oil Level 1 / Level 2) Chemical Endorsement (Level 1 / Level 2) STCW Certification Advanced Fire Fighting Proficiency in Survival Craft & RB Medical First Aid / Master's Medicare Personal Safety & Social Responsibility Personal Survival Techniques Fire Prevention & Fire Fighting Elementary First Aid Advanced Tanker Safety (TASCO) Petroleum Advanced Tanker Safety (TASCO) Chemical OTFC CTFC Automatic Radar Aids Radar Observer Radar Simulator Revalidation Course Other Certification Ship Security Officer / ISPS Bridge Team Management (BTRM / BRM) Bridge Simulator Engine Room Simulator Liquid Cargo Handling Simulator (LCHS) Inert Gas Systems Crude Oil Washing FRAMO ECDIS ISM Code English-Speaking Course Auditors Course INDOS Yellow Fever Vaccination Please give details of any other certificates held: Flag Endorsements for National Certificates Singapore COE Singapore Tanker Endorsement Singapore GMDSS Singapore Seaman Book Marshall Islands COE Marshall Islands GMDSS Endorsement Marshall Islands Seaman Book (CDC) Marshall Islands Basic Endorsement Marshall Islands Oil D.C. Endorsement Marshall Islands Chemical DC Endorsement Marshall Islands PSCRB Endorsement Marshall Islands Medical Person/SSO Endorsement Marshall Islands - Watchkeeping Endorsement

STCW Reg.

Grade

Cert.No.

Issued on

Issued at

Validity

Certification as mentioned above has been checked for accuracy and authority.

Manning Representative Signature & Stamp

Date

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NAVIG8 SHIP MANAGEMENT

B-210, 2nd Floor, EVEREST GRANDE, Shanti Nagar, Mahakali Caves Road, Andheri (East), Mumbai - 400 093, INDIA Details of Sea Service
In chronological order - last vessel posting at top of list Ref :

Vessel Name

Operators/ Managers/ Company

Type

Flag

Rank

NRT

Type of Main Engine and BHP (For Engineer Officers only)

From

To

MT- DAYS

Remarks / References

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
* Please do not give the Manning agents' references in the 'Operators' column, but instead give details of the actual vessel operators. ** If one page is not enough, please make copies of this page and attach to the application. Page 3 of 4

Ref : Deck Officers Cargoes Carried Trading Pattern Engineer Officers Type of Machinery : : TME : 2 STROKE DIESEL ENGINE SHIP IN CAMPUS TRAINING SHIP RANJHITA : Academic Qualification : __________________________________________ 10+2,BTECH MARINE ENGINEERING Pre-Sea Training Other Courses : BTECH IN MARINE ENGINEERING Percentage of Marks: 86,82.1,75

: _______________________________________________________________________________ STCW OTFC LGT CTFC STSDSD

Applicant's Medical History Height in Centimetres 178 cms Weight in Kg 70 kgs Yes Name of Vessel Date Signed Off No

Has the applicant has ever signed off from a vessel on medical grounds? If yes, please furnish details.

Reason / Brief Description of Illness / Injury / Accident

Have you visited the doctor in the last 12 months for any surgery / illness? If yes, please furnish details Yes Date of Illness / Surgery Details of Illness and Treatment received No

Please answer the below, by ticking the appropriate box: Were you ever denied a foreign visa? If yes, please furnish details. Are you willing to sail one rank lower ? Do you have any history of accidents during your sea service ? If yes, please give details on a separate sheet of paper. Have you been convicted in a court of law (whether civil or criminal)? Are any legal proceedings pending against you? Have you been associated with any radical groups? If yes, please give details on a separate sheet of paper. I hereby declare that all the details given in this application are true. Further, I understand that the company can hold me liable and refuse any claim for treatment, cost or any other Insured benefits if a complete and true statement of all previous illnesses has not been given. 05/02/2014 VISAKHAPATNAM Date and Place Yes Yes Yes Yes Yes Yes No No No No No No

P.SRINIVAS For office use only : Application details including sea service and reference checks are verified. Assessment of Candidate during Interview Scale Appearance (On a scale of 1 - 10) / Remarks 10 Attitude (On a scale of 1 - 10) / 10

English (On a scale of 1 - 10) / 10

Name and Signature of Interviewer / Manning Representative

Date and Place Page 4 of 4