OOSM Application Form - PRS-004

Solutions Pvt. Ltd.
Head office: 904-B, 9th Floor, Tower-B, Bestech Business Tower, Sector 66, Mohali, Chandigarh 160062
Branch: 502, Inspire, Boston House, Suren Road, Chakala, Andheri(E), Mumbai, Maharashtra - 400093
RPSL-MUM-162021 | DOI 07-Aug-2019 | DOE 07-Aug-2024 | ISO 9001:2015 | ISO 14001:2015 | OHSMS 45001:2018 | Tel: +91-172-4010909/79 |
PERSONAL DESCRIPTION AND INFORMATION
Insert Photo Here

Rank Applied For: Date of Availability:
NAME (As per Passport)

First Middle Last
Birth Date Place of Birth Nationality
Passport No. Place of Issue Date of Issue Date of Expiry

Visa Type Place of Issue Date of Issue Date of Expiry
U.S. Visa Type Place of Issue Date of Issue Date of Expiry
Permanent Address &

Contact Details
STD Code Res Mobile: Email:
Correspondence Address
& Contact Details
Marital Status No. of Children Nearest Airport
Next of Kin [Name, Name Relationship

Address & Contact
Name of Wife & Children Relation Place of Passport No. Date of Date of Place of issue ECNR
Date of Birth
Birth Issue Expiry
Certificate of Competency / COP /

Number Date of Issue Date of Expiry Place / Country of Issue
Watch-keeping
Revalidation Details
Seaman Book (CDC) Number Date of Issue Date of Expiry Place of Issue
Indian
Panama
Liberia / Palau
INDOS Number Height Weight BMI
PRS/004/Application Form Approved By: OOSM Issued: 01st June 2019

Rev 1.3: 01st May 2022
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Solutions Pvt. Ltd.
COURSES AND CERTIFICATION

Date of MTI & Place of
Name and Description Number Date of Issue
Expiry Issue
Basic Safety Training (if one certificate)
Elementary First Aid/Medical First
Aid/MEDICARE (refresher)
Personal Survival Techniques
Proficiency in Survival Craft & Rescue Boat
(refresher)
Personal Safety & Social Responsibility(2010)
FPFF/AFF (refresher)
Security Training for Seafarers (STSDS)/ISPS
Ship Security Officer
Ship Security Officer (refresher)
Bridge Team Management
Bridge Resource Management
Engine Resource Management
Vessel Resource Management
Crew Resource Management
ROC
ARPA/RANSCO/NARAS
GOC
GMDSS Endorsement
GTFC / GASCO
Gas DCE
CTFC / CHEMCO
Chemical DCE
OTFC/TASCO
Oil DCE
ECDIS
Ship Handling Simulator
Engine Room Simulator
COW/IGS
Yellow Fever Vaccination
Human Relations
Quality & safety Management
Risk Assessment / Risk Management
Marine Accident / Incident Investigation
Management of Change
Environmental Course / ISO 14001
MLC
Maritime Leadership Course
MARPOL I
MARPOL II
MARPOL VI
Maritime English
Crisis Management
Management of Major Emergencies

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Solutions Pvt. Ltd.
COURSES AND CERTIFICATION

Date of MTI & Place of
Name and Description Number Date of Issue
Expiry Issue
IMDG
Ship Safety Officer
Train the Trainer
Behaviour Based Awareness / Safety
Safety Awareness / Accident Prevention
Abrasive Wheel Regulations
Any Other Training:

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Solutions Pvt. Ltd.
th
Head office: 904-B, 9 Floor, Tower-B, Bestech Business Tower, Sector 66, Mohali, Chandigarh 160062
RPSL-MUM-162021 | DOI 07-Aug-2019 | DOE 07-Aug-2024 | ISO 9001:2015 | ISO 14001:2015 | OHSMS 45001:2018 | Tel: +91-172-4010900/9 | www.oceanoneshipmanagement.com
PREVIOUS SEA EXPERIENCE [Start with your latest vessel first]

FROM TO Total Manning
VESSEL TYPE FLAG RANK DWT BHP ENGINE dd-mmm- dd-mmm- Reason for Sign off
Months Days Agents/Owners
yyyy yyyy

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Solutions Pvt. Ltd.
ACTUAL TIME SERVED IN MONTHS (for officers only)

Rank GAS OIL TANKER RoRo / Bulk Carrier /
OTHERS
Master / Ch. Eng LNG LPG CRUDE PRODUCT CHEM Cont. Gen Cargo
Ch. Off / 2nd Eng mm dd mm dd mm dd mm dd mm dd mm dd mm dd mm dd
1st Off / Gas Eng
2nd Off / 3rd Eng
3rd Off / 4th Eng
R. Off / El. Off
Cadet / Jr. Eng
EDUCATIONAL BACKGROUND INCLUDINGPRE-SEA TRAINING

Name of School / College Attended / Institute Qualification
City / Country From To
(Pre-Sea Training) Achieved
REFERENCES:
Company Name Address
A
B
Person In charge Title Tel. No.
A
B
1) Are you involved in any marine accident / Investigations? Yes No (if YES please give details)
2) Are you currently under medical treatment or taking medication for existing conditions? Yes No (if YES please give details)
3) Did you suffer or do you presently suffer from any diseases likely to render you unfit for sea service or likely to endanger the health of other
persons onboard? Yes No (if YES please give details)
4) Did you undergo Psychiatric treatment? Yes No (if YES please give details as when you had undergone)
5) Are you addicted to Alcohol or Drugs of any kind? Yes No (if YES please give details)

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Solutions Pvt. Ltd.
BANK DETAILS:
Name of Bank Full Bank Address
Name of A/c Holder Branch Code
Account No. Swift Code
Declaration to be made and signed by Applicant:
I hereby certify and confirm that the information’s contained above is true and factual, relevant documents
wherever applicable will be shown on request. I have not withheld any information that would make my application
unfavourble.
I understand that a strict medical examination including Drug & Alcohol test as per company requirements is a
condition of my employment and I express my willingness to be examined. I undertake to provide the Company’s
medical officer full details of my previous medical history. I agree that the decision of the Company’s medical officer
is final.
I confirm that all my travel documents are valid and in order. I understand that if my travel documents at any time
during the course of my employment become invalid or restricted and cannot be revalidated by me under normal
process, making further travel or service by me is not possible, the contract of employment stands subject to
cancellation and all costs of repatriation will be borne by me. I am / am not presently committed to any other
company.
_______________________ ___________________
Date: Signature of Applicant
FOR OFFICE USE ONLY
VERIFICATION OF DOCUMENTS
Original COC / Passport / CDC Yes No Signature of Office Staff
STCW Courses and Training Certificates Yes No Signature of Office Staff
Signature of Manager [F.P.] Date:________________

Rev 1.3: 01st May 2022
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OOSM Application Form - PRS-004

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OOSM Application Form - PRS-004

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Solutions Pvt. Ltd.

PERSONAL DESCRIPTION AND INFORMATION

Insert Photo Here

NAME (As per Passport)

Passport No. Place of Issue Date of Issue Date of Expiry

Permanent Address &

STD Code Res Mobile: Email:

Marital Status No. of Children Nearest Airport

Next of Kin [Name, Name Relationship

Certificate of Competency / COP /

INDOS Number Height Weight BMI

PRS/004/Application Form Approved By: OOSM Issued: 01st June 2019

COURSES AND CERTIFICATION

PRS/004/Application Form Approved By: OOSM Issued: 01st June 2019

COURSES AND CERTIFICATION

PRS/004/Application Form Approved By: OOSM Issued: 01st June 2019

PREVIOUS SEA EXPERIENCE [Start with your latest vessel first]

PRS/004/Application Form Approved By: OOSM Issued: 01st June 2019

ACTUAL TIME SERVED IN MONTHS (for officers only)

EDUCATIONAL BACKGROUND INCLUDINGPRE-SEA TRAINING

PRS/004/Application Form Approved By: OOSM Issued: 01st June 2019

Name of A/c Holder Branch Code

Account No. Swift Code

Declaration to be made and signed by Applicant:

Signature of Manager [F.P.] Date:________________

PRS/004/Application Form Approved By: OOSM Issued: 01st June 2019

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