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MMSI
MMSI Application Form
MMS MARITIME (INDIA) PVT. LTD.
401/402 Raheja Plaza, 15/B Shah Industrial Estate, OffAndheri Link Road,Andheri (West), Mumbai 400 053. Maharashtra. India.
●Tel : 91-22-4062 0100 / 6696 0181 ● Fax : 91-22-6696 0183
NEW DELHI (BRANCH OFFICE)
115, First Floor, Rectangle 1, D-4, District Centre, Saket, New Delhi - 110 017 ●Tel: 91-11- 4613 6800 ●Fax : 91-11-4613 6804
● Email: apply@mms-india.com ● Website : http://www.mms-india.com

(As per Passport)

Post Applied for : First Name :
Middle Name :
Surname :
Willing to Accept Lower Rank?
Nationality :
Date of Birth :
Date Available From : Place of Birth :

Permanent Address: Present Address:

PIN: PIN:
Tel / Mobile: Tel / Mobile:
NearestAirport: E-Mail :

How did you come to know about MMSI ?

Number Date of Issue Place of Issue Date of Expiry Blank Pages ECNR
Passport
US Visa C1/D MUI
US Visa B1/B2 Membership No. :
Australian MCV

Seaman's Book: CDC Number Date of Issue Place of Issue Date of Expiry Remarks
Indian
Liberian
Panama
Others
INDOS
Yellow Fever

Licence Grade Number Date of Issue Place of Issue Date of Expiry

Indian
Liberian
Panama
UK
Singapore
Others

Civil Status:
Next of Kin Name Relationship:
FullAddress :
PIN :
Tel No.:
Family Details:
Name Sex Birth Date Passport No. Issue Date Issue Place Expiry Date ECNR US VISA
Wife F
Child 1
Child 2
Child 3

RPS Licence No:-RPSL-MUM-043

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 Name of the Duration Place of the
Details of Courses & Certificates Number Convention Date of Issue Date of Expiry
Institute Days Institute

10+2 School Details

Name of School / Institution From To Type of Degree

Pre Sea Training / Apprentice Ship

Name of Institute / College From To Type of Degree

MEDICAL HISTORY
(a) Have you ever signed off from a ship due to Medical reasons? (If Yes give details)

Name of Vessel(s) Date of Occurrence

Brief Description of Illness / Injury / Accident

(b) Did you suffer or are you presently suffering from any disease likely to render you unfit for service at sea or likely to
endanger the health of others on board.
(c) Are you addicted to alcohol or drug of any kind?

(d) Have you suffered from Malaria ? (e) Have you suffered from Diabetes ?

(g) Have you suffered from Epilepsy ? (g) Have you suffered from Nervous Disability ?

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 Previous Sea Service (Date Commencing from Last Vessel)
Sr. Name of Owners / Name of Vessel Rank Flag Vessel Type DWT GRT TEU BHP Engine Type UMS Y/N From To Total MM/DD Reason for
Manager Early Sign-Of

10

11

12

13

14

15

16

17

18

19

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23

24

25

26

27

28

29

30

31

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33

34

35

36

37

38

39

40

41

42

43

44

45

Sea service to Include Cadetship onward

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 REFERENCE Checked (For Office use only)
Name of the Company Address Yes No

Name of Person Title Phone 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; further, that no Certificate of Competency or Licence 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.

Date : Rank : Signature of Seaman :

(FOR OFFICE USE ONLY) (INITIAL INTERVIEW (Tick as applicable)

Original licences sighted YES Signature :

STCW and Training Certificates Sighted NO Signature :

Experience confirmed by interview YES

Other details confirmed by interview YES

A : GM (FP) : Signature :

B : Jt. Dir. (FP) Signature :

C : Dir & COO. : Signature :

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