Bellfranc Allied Services Pvt. Ltd.

BF-CRE-04
APPLICATION FORM CREW Page : 1 of 2
Date Of Issue : 15.05.2015 Effective Date : 15.05.2015

Reference No. :
Rank: wiper Date: 25-042018
Indos No: 15GL1565 Card No:
Family Name: Given Name: TANDEL MEHULKUMAR
PRAKASHBHAI
Permanent Add: AT PO MAGOD DUNGRI, MOTI CHHAPRI, VIA- ATUL,VALSAD PIN -396020

Pl & Date of Birth: 20-05-1994 Tel/Mob: 8511421371

Father’s Name: TANDEL PRAKASHBHAI Mother’s Name: TANDEL SADHANABEN
BHENKABHAI PRAKASHBHAI
Name next of Kin: TANDEL PRAKASHBHAI BHENKABHAI Relationship: FATHER
Address: AT PO MAGOD DUNGRI, MOTI CHHAPRI ,VIA- ATUL,VALSAD PIN- 396020
Email Id: tandelmehul1994@gmail.com Tel/Mob: 8511421371 D.O.B
Single/Married Wife’s Name:
Mumbai Address: Childs Name:
Childs Name:
Tel/Mob: Childs Name:
Bank: Address:
A/C Holder: Swift:

Number Issue Date Exp. Place

Date
Passport No. (Nationality : Indian ) M 0180517 21/07/2014 20/07/2024 SURAT
USA C1/D Visa
National Seaman’s Book MUM 263401 11/08/2016 10/08/2026 MUMBAI
Other Seaman’s Book (
)
Other Seaman’s Book
( )
Yellow Fever Vaccination 00195 21/09/2017 Lifelong MUMBAI

Number Issue Date Exp.Date Place

COP/ MMD Watch keeping Cert. Eng/Dk. Rating
STCW - Elementary First Aid (EFA) EFAU/C-1876/2015 14/03/2015 UDVADA
STCW - Fire Prevention Fire Fighting (FPFF) FPFU/C-154/2015 06/03/2015 UDVADA
STCW –Personal Survival Techniques (PST) PSTU/C-1598/2015 21/03/2015 UDVADA
STCW – PSCRB
STCW - PSSR PSR/C-9560/2015 18/03/2015 MUMBAI
STCW – (STSDSD) STSU/C-1905/2015 03/03/2015 UDVADA
STCW – Oil Tanker Familiarization Course RAM/OCTF/672 23/09/2017 MUMBAI
Oil Tanker Endorsement (DCE Oil) IMEI/HO/OT/12228 28/09/2017 MUMBAI
STCW – Chemical Tanker Familiarization Course RAM/OCTF/672 23/09/2017 MUMBAI
Chemical Tanker Endorsement (DCE Chemical) IMEI/HO/CT/6764 28/09/2017 MUMBAI
ISM Awareness Course
Cooks Certificate
Other Courses - Pre Sea Course PRS/H-1700/2015 05/05/2016 UDVADA
Other Courses AUG/FPFF RAM/FFOBT/2975 16/09/2017 MUMBAI
Other Courses

Revision : 1 Revision Date: 04 July 2017

 Bellfranc Allied Services Pvt. Ltd. BF-CRE-04
APPLICATION FORM CREW Page : 1 of 2
Date Of Issue : 15.05.2015 Effective Date : 15.05.2015

VESSEL NAME FLAG Off. No. TYPE GRT ENG. H.P. RANK From To
OCEAN QUEST INDIAN TUG 424 ENG. 07/11/16 12/05/17
RATING

PHOTO

1. Do you suffer from any ailments likely to render you unfit for sea service Yes/No
2. Do you suffer from any infectious disease Yes/No
3. Are you addicted to drugs or alcohol Yes/No

Signature: M.P.TANDEL

Received: _______________________________
Acknowledgement from Seaman
Date: ___________________________________ for Receipt of Application Copy.
Receipt of this Application Form is NOT a ________________ __________
Guarantee for Placement. Signature Date

M/S BELLFRANC A.S. PVT. LTD.

602, 6TH Floor,
DCIPL House, Bandra (W),
Mumbai 400050 (INDIA)
Licence No.: RPSL-MUM- 348
Valid until: 23.06.2020

Checked by: ___________________

Revision : INITIAL
1 VERIFICATION FINAL VERIFICATION
Revision Date: 04 July 2017
MD/DIR Date MD/DIR Date