Darya Shipmanagement Pvt Ltd.

FORM : PER -1
.

SEAFARER’S APPLICATION FORM

RANK APPLIED DATE OF APPLICATION

INDOS NUMBER DATE OF AVAILABILITY

1. PERSONAL DETAILS SURMAME FIRST NAME MIDDLE NAME

NAME

Date of Birth Place of Birth Nationality

Permanent
Present Address
Address
City & Pin Code : City & Pin Code :
Telephone : E-MAIL :

2. NEXT OF KIN / FAMILY PARTICULARS

NAME / RELATION
ADDRESS

NAME D.O.B PP/NO. ISSUED/VALIDITY

WIFE :
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 CERTIFICATES(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
PRE- SEA TRAINING
INSTITUTE

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Frequency: During Crew Selection
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6. LICENCE / CERTIFICATE OF COMPETENCY

Grade Number Date of Issue Date of Date of STCW 95

Expiry Revalidation YES NO
INDIAN
OTHERS

7. STCW AND OTHER CERTIFICATES

Issuing Authority/
STCW Courses Certificate No. Date of Issue Date of Expiry Place of Issue INSTITUTE
PSSR
EFA/MFA/MEDICARE
(First Aid)
PST/ PSCRB
(Survival)
FP & FF / AFF
(First Fighting)
ROC
ARPA
GMDSS
GMDSS END
REFRESHER & UPDATING
RANSCO / NARAS
S0MS/ NAV CONTROL
W/K CERT. FOR RATINGS
SIMULATOR TRAINING
ENGINE SIMULATOR
BTM
ECDIS
BRM/ ERM / VRM
TANKER COURSES
TASCO / TANKER FAM.
CHEMCO/ CHEM FAM.
GASCO/ GAS FAM.
DCE PETROLEUM
DCE CHEMICAL
DCE GAS
LIQUID CARGO SIM
OTHER COURSES
Safety Officers Cert/ ISPS ( SOC)

SSO
COOKERY COURSE
WELDING 2G,3G,6G

Version No: 01 Dated: 01-Jan-2015 Page 2 of 5

Approved by : CEO CONTROLLED DOCUMENT File: Office
Frequency: During Crew Selection
 Darya Shipmanagement Pvt Ltd. FORM : PER -1
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8. SEA EXPERIENCE: (Most recent first)

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

Any Major Incidence / Observation / Special Experience for reporting:

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Approved by : CEO CONTROLLED DOCUMENT File: Office
Frequency: During Crew Selection
 Darya Shipmanagement Pvt Ltd. FORM : PER -1
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9. REFERENCES (Please give two references/companies whom we can ask about your seagoing experience)
Name Company/ Telephone / Contact Name Company/
Designation No. Designation

REMARKS

9A. REF. CHECK

YES / NO

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

A Company presentation/seminar B C Marine magazine advertisement

D Newspaper advertisement E F Direct Mail from Company

G Other (Please Specify)

11. DECLARATION
I declare that the information given by me in filling up this from to the best of my knowledge are true and complete. I also declare
that the documents submitted to Darya Shipmanagement PVT LTD. 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:

12. SPACE FOR OFFICIAL USE

Assessment: Grade Application Status: Date :

Personality Forwarded Owners

Attitude OWNER’S ACCEPTANCE DETAILS
Technical Knowledge ACCEPTED YES NO
English Knowledge REF.

Over Assessment

Grade : A – Excellent, B-Good, C-Satisfactory,

D – Average. E- Poor

Interviewed by Date :

INTERVIEWER’S REMARKS:

Version No: 01 Dated: 01-Jan-2015 Page 4 of 5

Approved by : CEO CONTROLLED DOCUMENT File: Office
Frequency: During Crew Selection
 Darya Shipmanagement Pvt Ltd. FORM : PER -1
.

Version No: 01 Dated: 01-Jan-2015 Page 5 of 5

Approved by : CEO CONTROLLED DOCUMENT File: Office
Frequency: During Crew Selection