MARITIME TRAINING CENTRE

Date: 16.10.2017 Revision: 9.0 Prep: KND Appr : PKC Page 1 of 2

CCO
OUURRSSEE EENNTTRRYY FFO M –– SSEECCO
ORRM ONNDD M
MAATTEE ((FF..G
G))
Colour passport size
Fill in all particulars applicable CLEARLY IN CAPITAL letters. photo of candidate to be
pasted here.

Second Mate (FG) Course Date ______________

15-Nov-2022 Additionally
Course applied for: _______________________ One photograph to be
submitted along with
111 this application form.
Course Batch No.:______________ Indos. No.:____________________
PERSONAL PARTICULARS
FULL NAME : (as per your PASSPORT)
SURNAME:

GIVEN NAME(S):

Please mention your name as you want it to appear on your certificate

DATE OF BIRTH: (dd-mm-yyyy)

PLACE OF BIRTH:
NATIONALITY:
PERMANENT ADDRESS

PIN CODE:
TELEPHONE NUMBER: (specify the code if any)
MOBILE NUMBER:
E-MAIL ADDRESS:

ADDRESS IN DELHI / MUMBAI

PIN CODE:
TELEPHONE NUMBER: (specify the code if any)
DISCHARGE BOOK NUMBER:
PLACE OF ISSUE:
DATE OF ISSUE:

PASSPORT NUMBER:
PLACE OF ISSUE:
DATE OF ISSUE:

CERTIFICATE OF COMPETENCY DETAILS:

GRADE:
CERTIFICATE NUMBER:
PLACE & DATE OF ISSUE:
RECEIPT NO.
(Office Use Only) :

Form No. CO/10 B – Quality Manual AEMTC

 MARITIME TRAINING CENTRE
Date: 16.10.2017 Revision: 9.0 Prep: KND Appr : PKC Page 2 of 2

PRE-SEA MARITIME TRAINING

(NAME OF INSTITUTION
AND PLACE)

TYPE OF PRE-SEA COURSE :

YEAR OF PASSING OUT DGS APPROVED: YES NO

INDOS NO: DOI :

PROFESSIONAL PARTICULARS: SEA SERVICE
NAME OF SHIP (last five) Y M DAYS RANK

TOTAL SEA SERVICE :

PRESENT COMPANY
REFERENCE PERSON
TELEPHONE NUMBER: (specify the code if any)
MOBILE NUMBER: (specify the code if any)

STCW COURSES PSCRB GMDSS ROC ARPA

MFA AFF ECDIS
IS YOUR SHIPBOARD STRUCTURED
TRAINING PROGRAMME COMPLETE? YES NO

Please submit copies of documents mentioned below (Please Tick)

PASSPORT COPY PRE-SEA TRAINING CERTIFICATE
CDC COPY DLP CERTIFICATE
INDOS COPY SEA-TIME LETTER
2 PASSPORT PHOTOS 6 MONTHS WATCH-KEEPING CERTIFICATE
COPY OF PSSR, PST, EFA & FPFF CERTIFICATE INTRODUCTORY LETTER FOR AUTHORIZED SIGNATORY

DECLARATION:

I hereby declare, to the best of my knowledge, that the information given above is true. On admission, I undertake
to attend all classes regularly and punctually and to comply with all rules and regulation of the Training Center. I have not
been Restricted / Prohibited / Debarred from attending any courses or from appearing in any examination by D.G. Shipping
/ MMD / any other authority. I agree that fees once paid shall be non-refundable and non-transferrable.

Date: Signature of candidate:

VERIFIED BY: CHECKED BY:

REMARKS:
(Signature of Course in-charge)

DATE:

Form No. CO/10 B – Quality Manual AEMTC