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SUNTECH CREW MANAGEMENT PVT.LTD.

601 / A, 6th Floor, Supreme Chmabers, Off Veera Desai Road,

Andheri (West), Mumbai - 400 053, INDIA

RPSL NO. 320

For Office use only

Rank
Employment Code Approved

Rank Applied For Date of Readiness

Surname Self Name Father's / Middle Name Date of Birth Place of Birth Religion

Documents Number Issue Date Expiry Date Place of Issue

Passport

Indian CDC

Nationality Nearest Airport

Valid Visas Number Issue Date Expiry (Year) Place of Issue

US Visa C1/D

Contact Details
Present Address Permanent Address

PIN Code PIN Code

Telephone No. Mobile No. Telephone No. Mobile No.

E-Mail Address E-Mail Address

Family Details Marital Status Married / Bachelor

Relationship Surname Name Date of Birth Passport No. Issue Date Expiry Date Place of Issue

Next of Kin (Name) Relationship

Telephone No. Mobile No. E-Mail Address

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Certificates STCW Reg. Grade Cert.No. Issued on Issued at Validity
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

Certification as mentioned above has been checked for accuracy and authority.
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Details of Sea Service Ref :

In chronological order - last vessel posting at top of list

Type of Main Engine


Operators/ Managers/ Remarks /
# Vessel Name Type Flag Rank NRT and BHP (For From To MT- DAYS
Company References
Engineer Officers only)

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.
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Ref : 0
Deck Officers
Cargoes Carried :
Trading Pattern :

Engineer Officers
Type of Machinery :
:

Academic Qualification Percentage of Marks:

Pre-Sea Training :

Other Courses : _______________________________________________________________________________

Applicant's Medical History

Height in Centimetres cms Weight in Kg kgs

Has the applicant has ever signed off from a vessel on medical grounds? If yes, please furnish details.
Yes No

Name of Vessel Date Signed Off 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 No

Date of Illness / Surgery Details of Illness and Treatment received

Please answer the below, by ticking the appropriate box:

Were you ever denied a foreign visa? If yes, please furnish details. Yes No

Are you willing to sail one rank lower ? Yes No

Do you have any history of accidents during your sea service ? Yes No
If yes, please give details on a separate sheet of paper.

Have you been convicted in a court of Law (Civil / Criminal) ? Yes No


Are any legal proceedings pending against you ? Yes No
Have you been associated with any radical groups ? Yes No
Have any of your Certificates / Endorsements been Suspended or any procedding
pending against you by any of flag state administration. Yes No
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.

Signature of Applicant Date and Place

For office use only :

Application details including sea service and reference checks are verified.

Assessment of Candidate during Interview


Appearance (On a scale of 1 - 10) Attitude (On a scale of 1 - 10) English (On a scale of 1 - 10)
Scale
/ 10 / 10 / 10

Remarks

Name and Signature of Interviewer / Date and Place


Manning Representative
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