Professional Documents
Culture Documents
APPLICATION FORM
NOTES FOR APPLICATION FORM COMPLETION:
- Please ensure that the below application form is completed in word format.
- Once completed, please fill declaration box on last page and return form to us in word format only.
Full present address 7/110 kazuvanthittu vilai kalpadi kanya Kumari pin629204
(if different):
Airport distance
Nearest airport: Trivandrum 150
from address (km):
Email address: sijuthankaraj@gmail.com Contact number: +918248113620
Mobile phone
Skype address: +918248113620
number:
Blood group: B+ Positive / Negative: Positive
Height: 172 Weight: 70
PPE Safety shoe size: 9 PPE coverall size:
Issue date
INDOS number: 14EL3295 10/04/2014
(dd/mm/yyyy):
Full address:
Contact number: +
Mobile phone
Email address: +
number:
WPIF – M/03 09 th March 2019 Rev – 08
Page 1 of 9
Ryan Ship Management Private Limited
Company Registration Number- U45201MH2008PTC177718; ISO 9001:2015; RPSL MUM 126.
Office No. 1204/1205/1206, 12th Floor, Quantum Tower, C.T.S. No. 1, Rambaugh, Off S.V. Road, Chinchaoli, Malad (West), Mumbai- 400064, India.
Website: www.ryanshipbombay.com; Email: office@ryanshipbombay.com; Telephone: +91 222 844 56 30; Fax: +91 222 844 56 31.
YOUR APPLICATION
STCW
Certificate Place of
Name of Course / Certificate Code / Date of issue Date of expiry
number issue
Approvals
Non-prescribed Medications
Dosage Purpose / reason for taking
(please name)
SECTION 9- GENERAL
Particulars Yes / No
1. Have you ever been involved in a maritime accident, i.e. grounding, fire, explosion, collision No
2. Have you ever been rejected by Aramco / Shell or any other Charterer? No
3. Have you ever been the subject of a court of enquiry or involved in a maritime accident? No
4. Have you ever had a professional license suspended or revoked? No
5. Have you ever been convicted of any criminal offence? No
6. Have you ever been dismissed due to any reason? No
If you have answered Yes to any of the above then specify below
SECTION 11B- AHTS / AHT EXPERIENCE IF ANY (ONLY FOR DECK OFFICERS)
NUMBER OF DAYS WITH VARIOUS OPERATIONS
Vessel name Description of operations (please specify number of days)
(please put last vessel first, Anchor
voyage by voyage) Towing Rig move 4-point mooring
handling
Here at Ryan (hereafter referred to as Crew Managers), we take your privacy seriously and
treat your personal information with the utmost care. The information you provide will be
stored on our secure database and used in cases of:
Searching assignment and assignment management.
Where necessary to comply with laws, regulations or contracts applicable to any of the
employing companies or their businesses and in accordance with any limitation period.
Where necessary to protect your vital interests
Your personal information will never be sold to third parties or for marketing.
If at any point you believe the information we possess on you is incorrect you can request to
see this information and request to have it corrected or deleted. If you have any query or
complaint, please address any correspondence to our Data Protection Officer on email:
data@ryan-shipmanagement.com
I hereby declare that the above facts and information I have provided are true and accurate. I
acknowledge and accept that (i) the Owners/Managers of any vessel to which my application
and/or assignment is organised and (ii) the Crew Managers and associated companies may
each process my personal information (including any of my personal information provided at a
later date) for the purposes of searching assignment, managing assignment, compliance with
laws, regulations and contracts applicable to any of the employing companies or their
businesses and in accordance with any limitation periods and where necessary to protect my
vital interests.
I understand that my personal data will be stored in the Crew Managers’ secure database and
otherwise processed for the above purposes, in connection with, and during the period of my
current period of assignment and thereafter for such further period (if any) as is necessary to
fulfil the abovementioned purposes. I also understand that the abovementioned processing
activities may involve the transfer of my personal information from the Crew Managers to any
of the other companies. This may involve the transfer of my personal information to
jurisdictions whose data protection laws do not provide equivalent protection to my home
country subject to the companies taking appropriate measures to ensure that my personal
data is kept secure at all times. To the extent that my personal information includes sensitive
personal information, I consent to the Crew Managers processing such sensitive personal
information as stated above.
Please select appropriate box, print name, and date in acceptance of the above declaration:
Accepted:
☐ Yes Yes
☐ No
Seafarer name (full name): Thankaraj siju