SSS Maritime Services and Consultants Pvt. Ltd.

Seafarer Application Form

FR/CPM/CH-03/01
Rev;0
Address Tel
A- 301, Arjun Centre , Govandi Station road 022- 40153848
Govandi ( east), Mumbai - 400088. India 022 - 40155774
RPSL MUM 245 DOI - 02.05.2018 // DOE - 01.05.2023

Position Applied For: Date Of Application:

Are you willing to accept a lower Rank? Date Of Availability:
INDOS NO: Crew IPN:
PERSONAL DETAILS
1. GENERAL (Last name) (First Name) (Other Name)
Name:
Date/ Place Of Birth: Nationality:
Parmanent Address:

Post Code: (No.

E-mail Address: ÈNo.
Present Address:

(No.
Post Code: ÈNo.
Civil Status: Single/ Married/ Separated/ Divorced/ Widowed.
Height: cm: Weight: Kg:
Boiler Suit Size: Shoe Size:
2. FAMILY DETAILS
Full Name Of Next Of Kin: Relationship
Address Of Next Of Kin:
Post Code:
Contact Telephone No. (No. ÈNo.

Family Data Name D.O.B PPT. No. D.O.I P.O.I D.O.E

Wife
Child(M/F)
Child(M/F)
Child(M/F)
Child(M/F)

TRAVEL DOCUMENTS & VISA

Passport No. Date of Issue place of Issue Date of Expiry ECNR Blank Pages

U.S Visa MUI Membership No.

Type:

Any Other Visa

Yellow Fever
 ACADEMIC QUALIFICATIONS
School
College
Pre-Sea Training Institute

CERTIFICATIONS & COURSES

1. CDC DETAILS
Seaman's Book Number Date of Issue Date of Expiry Issuing Authority
Indian/ National
Liberian
Panamian
Marshall Islands
Bahamas
Cyprus
Other

2. LICENSES/ CERTIFICATE OF COMPENTANCY

License Grade Number Date Of Issue Date of Expiry Issuing Authority
Indian/ National
Liberian
Panamian
Marshall Islands
Bahamas
Cyprus
Other
3. DETAILS OF COURSES & CERTIFICATES.
Course Type Number Date of Issue Date of Expiry
Advanced/ Basic Fire Fighting/ FPFF
Proficiency in Survival Craft/ Rescue Boat/ PST
Elementary/ Medical First Aid/ Medicare
Personal Survival & Social Responsibility(PSSR)
Radar Observer/ ARPA
Radar Simulator (RANSCO)/ ENS
Ship Handling Simulator/ NARAS
LCHS
GMDSS
Specialised Petroleum Tanker Safety (STPOTO)
Specialised Chemical Tanker Safety (CHEMCO)
Specialised Gas Tanker Safety (GASCO)
Oil Tanker Familiarisation (OTFC)
Chemical Tanker Familiarisation (CTFC)
Gas Familiarisation (GTFC)
Ship Simulator/ Bridge Team Management
Engine Room Simulator
ECDIS
Bridge Team Management
Revalidation Course
ISM Code
ISPS/ Ship Security Officers Course/ CSO
Bridge/ Engine Room Resource Management
National Watch Keeping Certf. for AB/MTM/OILER
OTHERS
 MISCELLANEOUS
4. OIL DCE
License Level Number Date of Issue Date of Expiry Place of Issue
Indian/ National
Liberian
Panamian
Marshall Islands
Bahamas
Cyprus
Others
Others

5. CHEMICAL DCE
License Level Number Date of Issue Date of Expiry Place of Issue
Indian/ National
Liberian
Panamian
Marshall Islands
Bahamas
Cyprus
Others
Others

REFERENCES
References Person Name of company (No. ÈNo.

DECLARATION
I hereby affirm that all this information provided by me in this application is true and correct to the best of my knowledge and belief;
further, that no certificate off 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.

Date…………………………….. Rank…………………………….… Signature of Seaman………………………………

SPACE FOR OFFICIAL USE

Assessment: (1-5) Grade Application Status: Date:
Personality Forwarded To Dubai
Attitude Entered In Bass
Technical Knowledge Ex- Staff/ New
Overall Assessment
Others Specify

SMM:
s Pvt. Ltd.

Other Name)

ECNR

Blank Pages

D.O.E
suing Authority

Issuing Authority

Issued By
 Place of Issue

Place of Issue

ÈNo.

of my knowledge and belief;

I also certify that my medical
lness or injury will disqualify

…………

Date:
 PREVIOUS SEA SERVICE
(Date Commencing From Last vessel)
Name of
SR. Owners/ Engine Total Reason for
No. Manger Name of Vessel Type DWT GRT BHP Type Rank From To MM/DD S/Off

10

11

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13

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17

18

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20