FORM – 001

Date: 15.07.18

BANGLADESH MARITIME TRAINING INSTITUTE (BMTI)

Dhaka Office: House No. 38/A, Road No. 7, Sector – 3, Uttara, Dhaka, Tel # 02-8923080/913292 Fax # 02-8913045
Chittagong Office: Rummana Haque Tower, 1267/A, Goshail Danga, Agrabad C/A, Chittagong, Tel # 031-727350, Fax # 031-710288.
Http : www.bmti.org

Registration Form
Registration No: BMTI/2020/REF.MC/DEC/O2 PP Size
Color
1. Course Name: Medical Care (Refresher) PHOTO
2. Candidate’s Full Name: Mohammed Tariq Ali

3. Father’s Name: Shakoor Ahmed

4. Mother’s Name: Majeda Begum

5. Last Rank Held: Master

6. Date of Birth: 12-Jan-1979 Place of Birth: Gazipur

7. C.D.C. No./ P.P No: C/O/3627 Authenticated [By Administrator]

8. Total Sea Time (If Applicable): Abt 9 yrs

9. Competency Certificate Held (If Any): COC 1 Deck Singapore

10. Present Address: 645/C Zakir Hossen Road, West Khulshi, Chittagong

11. Permanent Address: 645/C Zakir Hossen Road, West Khulshi, Chittagong

12. Contact Telephone Number: +880 172 098 3449

13. Emergency Contact: Name: Mokaddasha Haque Chy Tel. No.: 0176 167 5995

14. Any Course Attended in BMTI (Tick in the box): Ancillary Preparatory
Y
15. Entry Qualification Met Y/N:

16. Any Health Condition/Deficiency:

17. Last sailing company: Unix Line Pte Ltd

18. Certificate Collect From: Dhaka Chittagong

Y
19. Documents Attached (Put Tick in the Box):

Y Photo copy of CDC Y Passport Photo Y NID / PP Photocopy

Other certificate (Pre-sea certificate for class 3 Deck/Engine, CoC for Class 2/1
deck/engine and CoP as required)

I, hereby, declare that the above information is correct to the best of my knowledge and
BMTI will not be responsible for any false or misleading information.

Capt Tariq Ali / 30 Dec 2020

______________________ _________________________
Administrator’s Signature Candidate’s Signature with date