GOVERMENT OF INDIA

MINISTRY OF SHIPPING
MMD MUMBAI
Application for DC Endorsement Basic (Level I)

Application No. : DCEB/MMD(M)/2022/21062

Application Date : 22-DEC-2022
Office Applied To MMD MUMBAI

Personal Details
Name of the Candidate : BRIJENKUMAR SANJAYBHAI PATEL

Date of birth : 29-MAY-1995 Place of birth : SURAT

Nationality : INDIAN INDOS No. : 18LL0101
Passport No. : R3699607 CDC No. : MUM 322086
CDC Issue Date : 21-JUL-2018 CDC Issue Place : MUMBAI
Application Details
Tanker Type : Oil Tanker
Rank : Electro Technical Officer

DCEB/MMD(M)/2022/21062
Grade : Electro Technical Officer CoC No. : ETO-06147
CoC Issue Date : 13-DEC-2022
DC Endorsement No. : IMEI/HO/OT/15651 DC Date of Issue : 02-NOV-2018
Address Details
House No. : 41 Street : Apnaghar Soc.
Village/Post Office : Palanpur Patia, Rander Road District : Surat
State : Gujarat Pin Code : 395005
Email Address : bpatel29051995@gmail.com Mobile No. : 8460298343
Cert. Receive Mode : By Post
Modular Course Details
Sr. No. Course Certificate No. Date of Issue

1 Fire Prevention & Fire Fighting GEIMS/FPFF/18/150/01 14-MAR-2018

2 Basic Training for Oil and Chemical Tanker Cargo Operations GEIMS/OCTCO/18/131/01 11-JUN-2018

Sea Service Details

Name of Vessel : Atlatic Harmony Vesel Type : Oil/Chemical Tanker

Port of Registry : MAJURO Rank Served : Assitant Electrical/Electronics Officer

From Date : 24-APR-2021 To Date : 13-DEC-2021

JET A1,ULSD, GASOLINE,GAS
Rank Held (Actual) : Assitant Electrical/Electronics Officer Cargo Carried : OIL,NAPTHA,REFOMATE

Name of Vessel : Atlatic Sirius Vesel Type : Oil/Chemical Tanker

Port of Registry : HONG KONG Rank Served : Assitant Electrical/Electronics Officer

From Date : 24-APR-2019 To Date : 04-AUG-2020

Rank Held (Actual) : Assitant Electrical/Electronics Officer Cargo Carried : JET A1,ULSD, GASOLINE,GAS OIL,SOYABEIN OIL

Fees Details
Amount (Rs.) : 3000 Payment Mode : ePayment

Payment Date : 22-DEC-2022 Reference No : YAX61633147723

Report generated on : 22/12/2022 8.57 PM Page 1 of 2

 Attached Documents
Sr. No. Documents to be uploaded

1 Scan copy of signed online application

Passport size (3.5 cm X 3.5 cm) photograph with clear white background face covering 70%
2

3 Scanned signature of seafarer

4 Scanned Modular Course certificate in one pdf file

5 Certificate from the company should mention the name of Oil,Chemical,Gas cargo carried along with their grade

6 Scan Copy of Existing Basic DC Endorsement Certificate

7 Self attested scanned copy of CDC booklet pages showing relevent sea services.

Declaration
I hereby declare that all the statements made in this application are true and complete to the best of my knowledge and belief and
nothing has been concealed/distorted.

I Agree.
Place : Signature of the Applicant :..................................................
...............................
Date : 22-DEC-2022 Name of the Applicant :BRIJENKUMAR SANJAYBHAI PATEL

DCEB/MMD(M)/2022/21062

Report generated on : 22/12/2022 8.57 PM Page 2 of 2