YUAM Shipping and Logistics Pvt. Ltd.

314, Midas, Sahar Plaza Complex, Andheri Kurla Road, Andheri (E), Mumbai-400059
Tel: + 91 22 66115000, Email : operations@yuamship.com
RPSL No. : RPSL-MUM-161

APPLICATION FORM / PERSONAL DATA UPDATE FORM

APPLIED TO OFFICE IN CITY / COUNTRY :

PRESENT RANK DATE OF APPLICATION

RANK APPLIED DATE OF AVAILABILITY

1. PERSONAL DETAILS SURNAME FIRST NAME MIDDLE NAME

NAME
Date of Birth Place of Birth Nationality
Permanent Address: Present Address:

City & Pin Code : City & Pin Code :

Telephone : Telephone :
E-mail 1 E-mail 2 :
Nearest Domestic Airport : Nearest International Airport::

2. NEXT OF KIN / FAMILY PARTICULARS

NAME / RELATION :
ADDRESS :
NAME D.O.B. PP/NO. ISSUED / VALIDITY
WIFE S
CHILD (M/F)
CHILD (M/F)
CHILD (M/F)
CHILD (M/F)

3. PASSPORT DETAILS

NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY

PASSPORT
US C1/D VISA
ECNR

4. CONTINUOUS DISCHARGE CERTIFICATE (S)

CDC NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY

INDIAN
LIBERIAN
OTHERS

5. ACADEMIC QUALIFICATIONS Grade/Degree From (Year) To (Year)

SCHOOL
COLLEGE
PRESEA TRAINING

REVISION : 1
6. LICENCE / CERTIFICATES OF COMPETENCY
Issuing Grade Number Date of issue Date of Date STCW 95
authority E Reval YES NO
x idatio
p n
ir
y
INDIAN
UK / AUS
LIBERIAN
SINGAPORE
OTHERS

7. STCW AND OTHER CERTIFICATES

STCW Courses Certificate No Date of Date of Place of Issuing
Issue Expiry Issue Authority/
INSTITUTE
PSSR
EFA / MFA / MEDICARE*
PST / PSCRB (Survival)*
FP & FF / AFF (Fire Fighting)*
ROC
ARPA
GMDSS
GMDSS END
REFRESHER & UPDATING
RANSCO / NARAS
SMS / NAV CONTROL
INDOS NO.
WATCHKEEPING
CERTIFICATE FOR RATINGS
CERTIFICATE REVAL.
COURSE
SIMULATOR TRAINING
ENGINE SIMULATOR
BTM (3 days / 5 days)*
ECDIS (3 days / 5 days)*
ICE NAVIGATION
BRM / ERM / VRM*
LARGE VESSEL HANDLING
SIMULATOR COURSE
TANKER COURSES
TASCO / TANK FAM*
CHEMCO / CHEM FAM*
GASCO / GAS FAM*
DCE PETROLEUM
DCE CHEMICAL
DCE GAS
LIQUID CARGO SIM
Crude Oil Washing Course

REVISION : 1
OTHER COURSES
ISPS / Ship Safety Officer*
HAZMAT
SSO
COOKERY COURSE
WELDING 2G,3G,6G
Risk Assessment & Management
Marine Accident and Incident
Investigation
OPA 90
VRP / VGP
Ship Security Awareness

*strike out as applicable

8. REFERENCES (Please give two references/companies whom we can ask about your seagoing experience)

Name Company/Designation Telephone/Contact NO.

1
2
REMARKS:

8A. REF. CHECK YES / NO

9. HOW DID YOU COME TO KNOW ABOUT US? (Please tick the appropriate medium) √

Company
A presentation/seminar B Marine Club notice-board C Marine magazine advertisement
D Newspaper advertisement E Told by seagoing friend (s) F Direct Mail from Company
G Others (Please specify)

10. PERSONAL DETAILS

Height : cm Weight : Kgs
Color of eyes: Color of Hair :
Any major illness / Surgery : YES / NO (If “YES”, Kindly provide details separately)

REVISION : 1
11. SEA EXPERIENCE: (Most recent at bottom)

VES
COMPANY SEL MAIN ENGINE PERIOD REASON FOR
NAME TYPE DWT GRT YEAR BUILD RANK MAKE MODEL BHP UMS FROM TO M/D SIGN - OFF

Special Experience:

REVISION : 1
12. DECLARATION

I declare that the information given by me in filling up this form to the best of my knowledge are true
complete. I also declare that the documents submitted are genuine, given and signed by the persons whose
names appear on them. Any false declaration may render me liable for termination or dismissal

Date : _____ SIGNATURE OF APPLICANT : ______________________

13. SPACE FOR OFFICIAL USE

Assessment : Grade Application Status : Date :

Personality Approval Status

Attitude
Technical Knowledge ACCEPTED YES NO
English Knowledge REF.

Overall Assessment

Grade: A = Very Good, B += Good, B = Satisfactory, C = Average, D = Below Average

Interviewed by __________ Date : _________

INTERVIEWER’S REMARK:

REVISION: 1