MMS MARITIME (INDIA) PVT. LTD.

MMSI
MMSI Application Form

PERSONAL DATA
Surname : Middle Name : KUMAR First Name : RAJESH

Nationality : INDIAN Date of Birth : 25-01-1968 Place of Birth : RAMPURA

Post Applied for : ENGINE FITTER Willing to Accept Lower Rank? Available From : (25 /12 /2017 )
ENGINE FITTER
Yes / No - NO DD/MM/YY

Permanent Address : Present Address :

48-A, SECTOR-2 , GANDHINAGAR, CHITTORGARH, 48-A, SECTOR-2 , GANDHINAGAR, CHITTORGARH,
RAJASTHAN RAJASTHAN

PIN Code : 312001 Nearest Airport: UDAIPUR PIN Code :312001

Tel No / Mobile No: 7976222650, 8233557212 Tel No / Mobile No: 7976222650, 8233557212
Email ID : rajeshpan1968@gmal.com

Passport No. Date of Issue Place of Issue Date of Expiry ECNR Blank Pages
H7145251 27-07-2009 BHOPAL 26-07-2019
US VISA 10-11-2014 MUMBAI 5-11-2019 MUI Membership #
Australian MCV

Seaman’s Book Number Date of Issue Place of Issue Date of Expiry Remark
(CDC)
Indian MUM82149 03-01-2014 MUMBAI 02-01-2014
Marshall Islands
Panamanian
INDOS 01XL3831 11-12-1998 MUMBAI -
Others

Licence Grade Number Date of Issue Place of Issue Date of Expiry

Indian
Marshall Islands
Panamanian

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UK
Singapore
Others

Civil Status : Single / Married / Separated/Divorced/Widowed MARIED

Full Name of Next of Kin : MADHURI PANWAR Relationship : WIFE
Address of Next of Kin : 48-A, SECTOR-2 , GANDHINAGAR, CHITTORGARH, RAJASTHAN

Tel No. : 8233557212, 8503876013

Family Data Name DOB PPT No. DOI Place of Issue DOE ECN
R
Wife MADHURI 07-09-1971
PANWAR
Child - F PRIYANKA 10-07-1991
PANWAR
Child - F AISHWARYA 29-08-1994
PANWAR

Details of Courses & Number Date Of Date Of Place of Issued by

Certificates Issue Expiry Issue
Advanced / Basic Fire Fighting / -
FPC/C - 140/2001 14-03-2001 MUMBAI
Fire Prevention & Fire Fighting
AFF Upgradation
PSC / PST PST/JA-179/1998 28-10-1998 - MUMBAI
MMTI/PSCRB/4005/200 -
PSC RB Upgradation 19-04-2008 MUMBAI
8
EFA / MFA / Medicare EFA/B-173/1999 18-02-1999 - MUMBAI
Personal Safety & Social Resp. -
PSSR-0/98-98 14-10-1998 MUMBAI
(PSSR)
Radar Observer / ROP
ARPA
Radar Simulator (RANSCO)
LCHS Management /
Operational
GMDSS
Petroleum Tanker Safety
Chemical / Gas Tanker Safety
TASCO /GASCO/CHEMCO
Upgradation
Petroleum Tanker
Familiarisation
Chemical /Gas Tanker
Familiarisation
Ship Manoeuvring Simulator

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 MMS MARITIME (INDIA) PVT. LTD.

ECDIS (IMO Model Course 1.27)

Bridge Team Management
Bridge Resource Management
Ship Security Officer Course
STSDSD
Tanker Vetting Inspection
Practical Marine Electrical
Workshop
NABCO
Engine Room Resource
Management
Engine Room Team
Management
Engine Room Simulator
Revalidation Course
Ref & Updating Training Course
Ship Safety Officer Training
Course
Petroleum Tanker Vetting Exam.
Watch keeping Certificate ER/MMD/MUM/3344 31/07/02 - MUMBAI
10-06- -
Maritime English/Marlin’s Test 2317 MUMBAI
2008
Dangerous Cargo Grade / Level Number Date of Place of Date Of
Endorsements I / II Issue Issue Expiry
DCE – Oil ( National) MS/0/1/E/15/0683 17-04-15 MUMBAI
The Data of the
flag DCE will be
captured here
DCE – Chem ( National) MS/C/1/E/15/0740 23-04-15 MUMBAI
The Data of the flag DCE
will be captured here
DCE - Gas ( National)
The Data of the flag DCE
will be captured here

Pre Sea Training / Apprentice Ship

Name of Institute / College From To Type of Degree

MEDICAL HISTORY
(a) Have you ever signed off from a ship due to Medical reasons? NO
(If Yes give details)
Name of Vessels Date of Occurrence

Brief Description of Illness / Injury / Accident

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 MMS MARITIME (INDIA) PVT. LTD.

(b) Did you suffer or Are you Presently suffering from any Disease likely to render you unfit for Yes / No
Service at Sea or likely to endanger the health of others on board.
(c) Are you addicted to alcohol or drug of any kind? Yes / No
(d) Have you suffered from following
Malaria Diabetes Epilepsy Nervous Disability

(e) Date of last Yellow Fever Date of Issue Date of Expiry

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Previous Sea Service (Date Commencing from Last Vessel)

Sr. Engine UMS Total Reason for

Name of Owners / Manager Name of Vessel Rank Flag Type DWT GRT BHP From To
No. Type Y/N MM/DD S/OFF

OIL/CHE. COMPLETION
1 FINAVAL SHIPPING M.T. ISOLA CELESTE ENG./FTR MALTA 30040 9480KW MAN B&W Y 25-03-17 12-10-17 6/18
TANKER OF CONTRACT
12000K MITSUI COMPLETION
2 FINAVAL SHIPPING M.T. NEVERLAND ENG./FTR MALTA OIL TANKER 56346 Y 23-05-16 19-02-17 9/7
W MAN B&W OF CONTRACT
OIL/CHE. 12900K DOOSAN COMPLETION
3 FINAVAL SHIPPING M.T. ISOLA CORALLO ENG./FTR MALTA 30723 Y 25-05-15 17-02-16 8/24
TANKER W MAN B&W OF CONTRACT
13560K STX MAN COMPLETION
4 ESSAR SHIPPING M.V. KISHORE ENG./FTR LIMASSOL BULK 62271 Y 3-02-14 06-09-14 7/4
W B&W OF CONTRACT
13560K STX MAN COMPLETION
5 ESSAR SHIPPING M.V. SHARAVAN ENG./FTR LIMASSOL BULK 62271 Y 09-02-13 24-10-13 8/16
W B&W OF CONTRACT
ENG./FTR. MONOROVI MITSUI COMPLETION
6 BSM M.V. APL GERMANY A
CONTAINER 66462 77770 Y 28-04-05 23-01-06 8/27
MM MAN B&W OF CONTRACT
M.V. APL HONG ENG./FTR. MONOROVI MITSUI COMPLETION
7 BSM A
CONTAINER 66573 63269 Y 22-04-04 11-02-05 9/21
KONG MM MAN B&W OF CONTRACT
M.V. APL HONG ENG./FTR. MONOROVI MITSUI COMPLETION
8 BSM A
CONTAINER 66573 63269 Y 15-10-02 26-09-03 11/12
KONG MM MAN B&W OF CONTRACT
M.V. GENCO ENG./FTR. HONG 18630K MITSUI COMPLETION
9 ANGLO EASTERN BULK 90106 Y 15-09-09 12-06-10 8/29
CONSTANTINE MM KONG W MAN B&W OF CONTRACT
M.V. FEDERAL ENG./FTR. MONOROVI KAWASAKI COMPLETION
10 ANGLO EASTERN A
G/CARGO 18825 7870KW Y 27-06-08 24-04-09 9/29
MARGAREE MM MAN B&W OF CONTRACT
M.V. FEDERAL ENG./FTR. BRIDGETO KAWASAKI COMPLETION
11 ANGLO EASTERN WN
G/CARGO 20837 8580KW Y 31-05-07 04-03-08 9/5
SCHLDE MM MAN B&W OF CONTRACT

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 MMS MARITIME (INDIA) PVT. LTD.

I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge
and belief; further, that no Certificate of Competency or Licence issued to me has ever been Revoked or Suspended. I also
certify that my medical history contained above is True and any false statement or undisclosed Material information
about past illness or injury will disqualify me from any employment benefits and claims.

Date ______________ Rank _____FITTER__________ Signature of Seaman _______________

(FOR OFFICE USE ONLY) (INITIAL INTERVIEW (Tick as applicable)

Original licenses sighted [ ] Checked [ ]

STCW and Training Certificates Sighted [ ] Checked [ ]
Experience confirmed by interview Yes [ ] No [ ]
Other details confirmed by interview Yes [ ] No [ ]

A : Dir. & COO: - VG / G / S / P Signature

B : JD / DD: - VG / G / S / P Signature

C : GM:- VG / G / S / P Signature

D: ____ :- VG / G / S / P Signature

WPIF-7.5/01 Effective Date: 01st June 2015

Rev No: 2

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