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FLEET PERSONNEL ADMINISTRATION

MIDEAST SHIP MANAGEMENT LTD

SEA STAFF APPLICATION FORM

PHOTO

APPLICATION FOR POSITION AS THIRD OFFICER OTHER POSITION (IF ANY) -

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1. PERSONAL DETAILS
TITLE MR/MRS/MISS MR SEX MALE FEMALE
SURNAME YADAV
FIRST NAME SUKENDER OTHERS NAMES SUKHI
DATE OF BIRTH 30/12/1991 PLACE OF BIRTH REWARI,HARYANA
NATIONALITY INDIAN MARITAL STATUS SINGLE
COLOUR OF EYES BLACK COLOUR OF HAIR BLACK
MOTHER’S NAME KRISHNA DEVI FATHER’S NAME SURENDER SINGH
MOTHER’S MAIDEN NAME -
HEIGHT (CM) 180 CM WEIGHT (KG) 86 KG
NEAREST INTERNATIONAL AIRPORT: NEW DELHI
2. ADDRESS ADDRESS (TEMP.) FROM/TO:
NO & STREET VILLAGE-SIHA,PO-LUHANA, NO & STREET

CITY REWARI CITY

POST CODE 123411 POST CODE
COUNTRY INDIA COUNTRY
TEL. NO. - TEL. NO.
MOBILE +919991295421 MOBILE
E-MAIL Sukhi373@gmail.com E-MAIL
FAX - FAX
3. NEXT OF KIN
FULL NAME SURENDER SINGH RELATIONSHIP FATHER
ADDRESS SAME AS ABOVE
CITY REWARI COUNTRY INDIA
TEL. NO. MOBILE +919991295421 FAX NO.
4. CHILDREN
FULL NAME OF CHILD DATE OF BIRTH SEX
M F
M F
M F
M F
5. TRAVEL DOCUMENTS
TYPE DOCUMENT NO. ISS.DATE EXP. DATE ISS. BY (AUTHORITY) PLACE OF ISSUE
PASSPORT J7478948 11/05/2011 10/05/2021 GOVT.OF INDIA DELHI

SEAMAN BOOK MUM193935 24/10/2011 23/10/2021 DG SHIPPING MUMBAI

OTHER SEAMAN BOOK

US C1/D VISA F5361439 16/05/2012 14/05/2017 US GOVT. MUMBAI

OTHER VISAS
6. BANK ACCOUNT INFORMATION
BANK NAME SBI BRANCH BRASS MARKET
BANK ADDRESS BRASS MARKET,REWARI,HARYANA

CITY REWARI COUNTRY INDIA

SORT CODE - ACCOUNT NO 31602623160

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BANK SWIFT CODE SBIN0011871 BANK TEL. NO 01274223579

ACCOUNT OWNER’S NAME SUKENDER YADAV

ACCOUNT OWNER’S ADDRESS VILLAGE-SIHA,PO-LUHANA,REWARI,HARYANA

7. EDUCATION
SCHOOL NAME 12TH,JEEVAN JYOTI SR. SEC. PUBLIC SCHOOL FROM 2009 TO 2010

SCHOOL NAME B.S.C NAUTICAL SCIENCE(T.S CHANAKYA MUMBAI) FROM 2011 TO 2014

8. PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY

EXPIRY ISSUED BY
CERTIFICATE NAME NUMBER ISSUE DATE ISSUED AT
DATE (AUTHORITY)
INDIAN COC 2 MATE FG IF-33264 30/10/2015 08/10/2020 DG SHIPPING MUMBAI

DANGEROUS CARGO ENDORSEMENT NUMBER ISSUE DATE EXPIRY DATE

PETROLEUM M/O/1/N/12/13751 10/03/2017 UNLIMITED

CHEMICAL M/C/1/N/12/13818 31/03/2017 UNLIMITED

GAS
9. LANGUAGES
ENGLISH FLUENT GOOD FAIR POOR

GERMAN FLUENT GOOD FAIR POOR

FRANCH FLUENT GOOD FAIR POOR

SPANISH FLUENT GOOD FAIR POOR

ITALIAN FLUENT GOOD FAIR POOR

RUSSIAN FLUENT GOOD FAIR POOR

MARLIN’S TEST / ISSUED

RESULT % ISSUED BY (AUTHORITY) ISSUED AT
LEVEL DATE

10. HEALTH CERTIFICATES & VACCINATIONS

ISSUE EXPIRY ISSUED BY
FLAGE STATE NUMBER ISSUED AT
DATE DATE (AUTHORITY)
INTERNATIONAL
LIBERIAN
NORWEGIAN
PANAMANIAN
EXPIRY
NAME ISSUE DATE ISSUED BY (AUTHORITY) ISSUED AT
DATE
YELLOW FEVER 12/11/2011 11/11/2021 GOVT.OF INDIA DELHI

11. SAFETY CLOTHING

BOILERSUIT SIZE XL BOOTS SIZE US 10

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12. MARINE COURSES

ISSUE EXPIRY ISSUED BY
COURSE NAME NUMBER ISSUED AT
DATE DATE (AUTHORITY)
PERSONAL SURVIVAL PR5869 01/07/2016 SETRAC MUMBAI
BASIC FIRE FIGHTING FR5880 01/07/2016 SETRAC MUMBAI
CMETL/AFF/464/488
ADV. FIRE FIGHTING 24/01/2015 CMET LUCKNOW
0
ELEMENTARY FIRST AID E7620 06/07/2016 SETRAC MUMBAI
MEDICAL FIRST AID MA15024 26/02/2015 ARI DELHI
MEDICAL CARE
PERS. SAFETY & SOC. RESP. PSR/15/0393 27/05/2015 AQUATECH DELHI
PROF. IN SURVIVAL CRAFT & CMETL/PSCRB/175/2
31/01/2015 CMET LUCKNOW
RESCUE BOATS 574
FAST RESCUE CRAFT
G.M.D.S.S. D-5042 21/05/2015 ARI DELHI
A.R.P.A. (Management level) AR15060 20/03/2015 ARI DELHI
RADAR OBSERVATION RO15049 14/03/2015 ARI DELHI
HAZMAT
OIL TANKER BPMA/TFC/567/2011 22/07/2011 BP MARINE MUMBAI
NATCOM/STPOTO/0
ADVANCE OIL TANKER 10/03/2017 NETCOM GURGAON
23/2017
CHEMICAL TANKER BPMA/CTFC/580/2011 29/07/2011 BP MARINE MUMBAI
ADVANCE CHEMICAL TANKER SCT 17025 31/03/2011 ARI DELHI
GAS TANKER BPMA/LGT/505/2011 15/07/2011 BP MARINE MUMBAI
ADVANCE GAS TANKER - -
CRUDE OIL WASHING
INERT GAS PLANT
ISM CODE
SHIP SECURITY OFFICER SSO17062 17/03/2017 ARI DELHI
BRIDGE TEAM MANAGEMENT
DP INDUCTION
DP SIMULATOR
BRIDGE / ENGIINE ROOM
RESOURCE MANAGEMENT.
SHIP HANDLING
INTERNAL AUDITORS COURSE

12. MARINE COURSES (CONTD……)

ISSUE EXPIRY ISSUED BY
COURSE NAME NUMBER ISSUED AT
DATE DATE (AUTHORITY)
B.S.C NAUTICAL SCIENCE 02220 30/05/2016 UNLIMITED IMU MUMBAI

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13. SPECIALISED EXPERIENCE

TYPE FROM TO COMMENTS
NEW BUILDING
SPECIALISED PROJECTS
SPECIAL TRADES
SHORE EXPERIENCE

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COMPLETE SEA – SERVICE DETAILS

( LAST VESSELS FIRST )
RANK: AVALIABILITY
NAME: SUKENDER YADAV THIRD DATE:
OFFICER 15/04/2017
PERIOD
ENGINE TYPE
SIGNED SIGNED IN TYPE OF
COMPANY NAME RANK VESSEL NAME MONTHS D.W.T. ( ENGINEERS BHP KW
ON OFF VESSEL
ONLY)
(eg 4.2)
DECK
CADE BULK 27128 6565
CAMPBELL SHIPPING T M.V CS MANATEE 06/06/2012 02/10/2012 3M/26D CARRIER
DECK BULK
CADE CARRIER 27128 6565
CAMPBELL SHIPPING T M.V CS MANATEE 7/11/2012 11/07/2013 8M/4D
DECK 9840
CADE PRODUCT 32984
CAMPBELL SHIPPING T M.T SORAYA 19/09/2013 13/08/2014 10M/24D TANKER
THIRD
OFFIC OIL/CHEM. 30420 6480
CAMPBELL SHIPPING ER M.T CAROLINE 14/11/2015 28/04/2016 5M/15D TANKER
THIRD 6M/12D
OFFIC 37713 9297 6820
CAMPBELL SHIPPING ER M.V CS JENNA 24/07/2016 06/02/2017 LOG CARRIER

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REFERENCE CONTACT DETAILS

COMPANY NAME CAMPBELL SHIPPING
ADDRESS KHAR ROAD MUMBAI
PHONE NO. +919769005791
FAX/E-MAIL -
CONTACT PERSON SANDRA SQUERIA

I declare that the information I have given is, to the best of my knowledge, true and complete. I also declare that the documents submitted are genuine, given and sign by
persons whose names appear on them.

DATE SIGNATURE

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Ref .No  
Officer Application Form
(For Official Use)  
Medical History
Have you ever signed off from a ship due to medical reasons?
NO 
(If yes give details) *yes/no
 
Date of occurrence
Name of Vessel (dd-mmm-yyyy)
   

   
Brief Description Of illness/Injury/Accident  

Details
Have you ever suffered from any ailment or disease in the past that is likely to render you  NO  
unfit for sea service or likely to endanger the health /well being of others onboard?

(If Yes give details) *Yes/No  

  Details
Do you have any bodily defects or deficiencies?  NO  

(If Yes give details) *Yes/No  

  Details
Are you currently suffering from any ailment or disease that is likely to render you unfit for  NO  
sea service or likely to endanger the healthy /well being of others onboard?

(If Yes give details) *Yes/No  

  Details
Are you addicted to alcohol or drug of any kind?  NO  

(If Yes give details) *Yes/No  

  Details
Are you suffering from an ailment that requires you to be on a long -term  NO  
treatment/medication?

(If Yes give details) *Yes/No  

  Details
Have you ever deported or banned from entering any country?  NO  

(If Yes give details) *Yes/No  

  Details
Have you ever been convicted of a criminal or drug offence or have any pending offences?  NO  

(If Yes give details) *Yes/No  

  Details
Do you have any obligations towards your current/previous employers?  NO  

(If Yes give details) *Yes/No  

 
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 License 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.
 
…………………………………….. ……………………………………..
dd-mmm-yyyy (Format) Signature

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