AFFIX

APPLICATION FORM PASSPORT SIZE

PHOTO HERE

Position Applied for Date Available to join

How were you Advertisement – Seamen’s Club / Newspaper / Shipping Publication

introduced to Chellaram Internet – Company’s website / Other site (name it)
Shipping? Friend(s) – in Chellaram Shipping / not in Chellaram Shipping
Others – (Specifiy)
Personal particulars

INDOS No.

Name (as per passport) Last First: Middle:

Date of Birth : Age Place of Birth
Height Weight
Nationality Religion
Mother Spoken Languages
tongue Written Languages
Native Place Currently resident
Marital Status Single Married Divorced Separated Widowed

Permanent Address

Tel No. Mobile E-mail

Present Address

Tel No. Mobile E-mail

Family particulars

Next of Kin Name Relationship

Address

Tel No. E-mail

Name Sex D.O.B./P.O.B. PP No. ECNR Date/Place Issued

Wife xxx Yes No
Child –1 Yes No
Child –2 Yes No
Child –3 Yes No
Educational Background - prior Pre-Sea Training

Name: School / College From To Percentage Position/Degree/Diploma

Marks Scored
Pre-Sea Training
Deck Officers - if no Pre Sea training done, then state the “Direct” cadet period.
Engineer Officers - to additionally state the name of the workshop attended
Pre Sea Training Institute
Date Commenced Date Completed
Degree/Diploma/Certificate Class Obtained
Name of Workshop
Personal Identity Documents Held
Documents Country Number Issue Date Expiry Date Place of Issue
Passport
US C1/D Visa XXXXXXXX
ECNR Yes No
Indian CDC
Seaman book

Have you ever been rejected for any Visa applied for? Yes No
Certificate of Competency
State details of highest Certificate of Competency held
Certificate Grade Issuing Country Certificate No. Date Issued Place Issued Valid Until

Certificate of competency & ATO issued by Hong Kong:

Certificate / License Certificate No. Date of Issue Place of Issue Valid Until
Hong Kong License
Authority To Operate (ATO)
Courses attended and Certificates obtained

Course Institute / Place Certificate No. Date Issued Valid Until

Elementary First Aid
Medical First Aid
Ship Master’s Medicare
Personal Survival Techniques
PSC – RB
Fire Fighting & Fire Prevention
Advance Fire Fighting
PSSR
Radar Observer
ARPA
Radar Simulator / RANSCO
Ship / Engine Simulator
ECDIS
GMDSS
STCW Endorsement
ISO / ISM Auditor Course
Bridge Team Management
Bridge Resource Management
AMOS-4W Course
Computer Literacy

Applications familiar (Word, Excel, etc.) Yes No

Planned Maintenance System (PMS) Yes No
Training Undergone for AMOS4W Yes No
ISPS course Yes No
SSO course (Maritime Administration Approved) Yes No
Medical History

Have you ever signed off from any ship on medical grounds? Yes No
Have you undergone any operation / surgery in the past? Yes No
Are you suffering or suffered from any major illness? Yes No
Have you been taking any medicine regularly? Yes No
If Yes, then what are these medicines?
Which medicines you have to carry with you on board?
Do you have any health or disability problems now? Yes No

If the answer is “Yes” to any of above, then give full details hereunder and attach a separate page, if necessary

Yellow Fever Vaccination (Date & Place of Issue)

General

Have you ever been involved in a court of enquiry or maritime accident? Yes No
Have you ever had your Certificate of Competency suspended or revoked? Yes No
If the answer is Yes to any of above, then give full details hereunder and attach a separate page, if necessary.

References
State details of the Superintendent / Manager of your current or immediate past employers as below:

Name of Company Superintendent/Manager’s Name & Designation Telephone

Kindly fill up sea experience in the attached sheet

Declaration

I do hereby declare that all information furnished above is true to best of my knowledge and belief.
I further declare that prior to joining you, I will stand released from previous employment.
I do hereby pledge that I have never abused any drugs in the past.

If immediate employment is not available do you wish to be considered for future vacancies - Yes No
Signature Date
Sea Experience
Enter from descending order, i.e. latest ship first
Use abbreviations: GC- General Cargo MP - Multi-Purpose CN – Container RF - Refrigerated RR- RO/RO HL - Heavy Unit
LS- Lash type PS - Passenger DR - Dredger LV- Livestock BC - Bulk Carrier OBO - Ore/Bulk/Oil
TN – Tankers PD -Product GS - LPG/LNG CH - Chemical Tanker OS - Off-shore PCC - Pure Car Carrier
RECORD OF PREVIOUS SEA SERVICE

COMPANY VESSEL RANK FROM TO PERIOD VESSEL ENGINE UMS BHP GRT YEAR DRYDOCK REASONS FOR LEAVING
DONE
dd/mm/yy dd/mm/yy M D TYPE TYPE BUILT COMPANY
N-UMS

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

TOTAL RANK EXPERIENCE IN MONTHS:

MASTER CHIEF ENGINEER ELECTRICAL OFFICER
CHIEF OFFICER 2nd ENGINEER
2nd OFFICER 3rd ENGINEER
3rd OFFICER 4th ENGINEER
DECK CADET 5th ENGINEER / TME
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