Director General of Shipping Approved License No.

RPSL/CHN/025
#311, Plaza Centre, No.129, G.N.Chetty Rd., Chennai - 600 006, INDIA.
Tel: +91 44 4264 9334, +91 44 6410 8334 Fax:+91 44 4354 6291 E- Mail: crewing@ioms.in

MUMBAI Office: A-63/64, HAWARE CENTURION MALL,SECTOR -19A,NERUL(E),NAVI

MUMBAI -400706,INDIA.Tel:+91 22 2770 0118 E-Mail: crewing@ioms.in

Rank Applied For: Date of Availability:

Agency Applied Through IOMS Docs with agency : Yes No

PERSONAL DESCRIPTION AND INFORMATION

NAME (As per Passport)
First Middle Last
Birth Date Place & Country Nationality

Passport No. Place of Issue Date of Issue Date of Expiry

Senghen Visa Type Place of Issue Date of Issue Date of Expiry
U.S. Visa Type Place of Issue Date of Issue Date of Expiry

Permanent Address &

Contact Details

STD Code Res Mobile: Email:

Correspondence Address
& Contact Details
STD Code Res Mobile: Email:

Marital Status No. of Children Nearest Airport

Next of Kin [Name, Name Relationship

Address & Contact
STD Code Res Mobile: Email:

Name of Wife & Children Relation Date of Place of Passport No. Date of Date of Place of issue ECNR
Birth Birth Issue Expiry

Place / Country of
Certificate of Competancy Number Date of Issue Date of Expiry Issue

Revalidation Details

Seaman Book (CDC) Number Date of Issue Date of Expiry Place of Issue
Indian
Panama

Document No: IOMSPL/ FF/ 02/ 04, Issue: 1, Rev: 0, Dt:10-05-2013

 COURSES AND CERTIFICATE (STCW -2010) & OTHER MODULAR COURSES.
Name and Description Number Date of Issue Date of Expiry Place of Issue
Elementary First Aid
Personal Survival Techniques
Proficiency in Survival Craft
Personal Safety & Social Responsibility
Fire Prevention & Fire Fighting
Proficiency in Survival Craft & Rescue Boat
Security Training for Seafarers (STSDS)
Watch Keeping Deck
Certificate Engine
Ships Captain Medicare
Medical First Aid
Advanced Fire Fighting
I.S.P.S.
Bridge Team Management
Level
Engine Room Simulator
Level
Ship Security Officer
Ship Handling Simulator
Country: ______________
GMDSS Endorsement: __________
Refresher & Updating Training
Yellow Fever Vaccination
INDOS
ISM

PREVIOUS SEA EXPERIENCE OF LAST FIVE YEARS [Start with your last vessel served]
TOTAL Manning
FROM TO
VESSEL TYPE RANK DWT BHP ENGINE Agents /
dd/mm/yy dd/mm/yy
Mnts Dys Owners

EDUCATIONAL BACKGROUND INCLUDINGPRE-SEA TRAINING

Name of School / College Attended / Institute Qualification
City / Country From To
(Pre-Sea Training) Achieved

Document No: IOMSPL/ FF/ 02/ 04, Issue: 1, Rev: 0, Dt:10-05-2013

REFERENCES:
Company Name Address
A
B
Person Incharge Title Tel. No.
A
B

1) Are you involved in any marine accident / Investigations? Yes No (if YES please give details)

2) Are you currently under medical treatment or taking medication for existing conditions? Yes No (if YES please give details)

3) Did you suffer or do you presently suffer from any diseases likely to render you unfit for sea service or likely to endanger the health of other
persons onboard? Yes No (if YES please give details)

4) Did you undergo Psychiatric treatment? Yes No (if YES please give details as when you had undergone)

5) Are you addicted to Alcohol or Drugs of any kind? Yes No (if YES please give details)

BANK DETAILS:
Name of Bank Full Bank Address

Name of A/c Holder Branch Code

Account No. Swift Code

I hereby certify and confirm that the information’s contained above is true and factual, relevant documents wherever applicable
will be shown on request.
___________________
Date: Signature of Applicant

FOR OFFICE USE ONLY

VERIFICATION OF DOCUMENTS
Original COC / Passport / CDC Yes No Signature of Office Staff
STCW Courses and Training Certificates Yes No Signature of Office Staff

Signature of Manager [F.P.] Date:

Document No: IOMSPL/ FF/ 02/ 04, Issue: 1, Rev: 0, Dt:10-05-2013