PRE DOCUMENTATION CHECKLIST & RECORD Synergy Maritime Recruitment Services Pvt Ltd.

(Copies of all documents must be kept in candidate's folder)

Crew Code 16094 Name Roshanbhai Subhashchandra Morekar Rank Able Bodied Seamen Date 08/Nov/2021 Vessel Name KIM OLDENDORFF Flag PORTUGAL

Verified by
S.No Document Name Document Number Place of Issue Date of Issue Date of Expiry
Man.
Master
Exec.
1 EMPLOYMENT CONTRACT CHE/REG/2021/12860 Chennai 08/Nov/2021 07/Aug/2022
DOCUMENTS
JOINING

2 LETTER OF UNDERTAKING

3 PRE-JOINING MEDICAL REPORT

4 DRUG & ALCOHOL TEST REPORT

5 PASSPORT Z3330472 SURAT 03/Nov/2015 02/Nov/2025

6 NATIONAL SEAFARERS IDENTIFICATION BOOK (SIB)/ CONTINUOUS DISCHARGE ERTIFICATE (CDC) MUM 156144 Mumbai 03/Aug/2018 02/Aug/2028
7 CERTIFICATE OF COMPETENCY (COC)/WATCHKEEPING DR/MMD/MUM/17080 MUMBAI 24/Nov/2009
MANDATORY FOR ALL RANKS

8 PROFICIENCY IN SURVIVAL CRAFT AND RESCUE BOAT (PSCRB)/PERSONAL SURVIVAL TECHNIQUES (PST) 20100162122128316 MUMBAI 05/Jul/2021 04/Jan/2023
9 ADVANCED FIRE FIGHTING (AFF)/FIRE PREVENTION AND FIRE FIGHTING(FPFF) 20407461222104018 MUMBAI 12/Aug/2021 11/Feb/2023
10 MEDICARE/MEDICAL FIRST AID (MFA) / ELEMENTRY FIRST AID (EFA) AMA2/EFA/B36/09/15 MUMBAI 02/Dec/2015 01/Dec/2020
11 PERSONAL SAFETY AND RESPONSIBLITIES (PSSR) PSRU/K - 2323/2016 GUJARAT 23/Nov/2016 22/Nov/2021
12 YELLOW FEVER 2045 MUMBAI 30/Jan/2009 29/Jan/2029
13 VISA

14 MUI MEMBERSHIP CARD

15 INDIAN NATIONAL DATABASE OF SEAFARERS (INDOS) 08GL1172 MUMBAI

16 SHIP SECURITY OFFICER (SSO)/SECURITY TRAINING FOR SEAFARERS WITH DESIGNATED DUTIES (STSDSD) RAM/SSDS/7935 MUMBAI 28/Sep/2018 27/Sep/2023

17 GENERAL OPERATOR CERTIFICATE (GOC)

DK OFFICER/ENG

18 NATIONAL GENERAL MARITIME DISTRESS AND SAFETY SYSTEM (GMDSS)

OFFICER

19 RADAR ARPA & NAVIGATION SIMULATOR (RANSCO)/RADAR OBSERVER COURSE (ROC)

20 AUTOMATIC RADAR PLOTTING AIDS (ARPA)

21 BRIDGE TEAM MANAGEMENT (BTM)

22 SHIP MANVG SIMULATOR

23 ENGINE RESOURCE MANAGEMENT (ERM)

24 FLAG LICENSE/RANK ENDORSMENT

25 SHIP SECURITY OFFICER (SSO)/SECURITY TRAINING FOR SEAFARERS WITH DESIGNATED DUTIES (STSDSD)
DOCUMENTS

26 FLAG SEAFARERS IDENTIFICATION BOOK (SIB)

FLAG

27 FLAG GENERAL MARITIME DISTRESS AND SAFETY SYSTEM (GMDSS)

28 FLAG DANGEROUS CARGO ENDORSEMENT OIL

29 FLAG DANGEROUS CARGO ENDORSEMENT CHEM

30 FLAG DANGEROUS CARGO ENDORSEMENT GAS

Ed 01 Rev No 0
Date: 10-Jan-2020
FORM : M 09 Page 1 of 2
 PRE DOCUMENTATION CHECKLIST & RECORD Synergy Maritime Recruitment Services Pvt Ltd.
(Copies of all documents must be kept in candidate's folder)

31 TASCO/CHEMCO/GASCO - All Officers & Engineers

32 NATIONAL DANGEROUS CARGO ENDORSEMENT OIL

33 NATIONAL DANGEROUS CARGO ENDORSEMENT CHEM

OIL/CHEM/GAS

34
NATIONAL DANGEROUS CARGO ENDORSEMENT GAS

35 TASCO/CHEMCO/GASCO - Only Junior Officers

36 LIQUID CARGO HANDLING SIMULATOR COURSE OPT/MGT (OIL) (LCHS)

37 OIL TANKER FAMILIARIZATION (OTF) - Junior Offrs, Engrs/ Crew/ Cadets

38 CHEMICAL TANKER FAMILIARIZATION (CTF) - Junior Offrs, Engrs/ Crew/ Cadets

39 GAS TANKER FAMILIARIZATION (GTF) - Junior Offrs, Engrs/ Crew/ Cadets

40 AUSTRALIAN MARINE CREW VISA

41 VESSEL GENERAL PERMIT (VGP) (US Calling vsls)

OTHERS

42 SAFETY OFFICERS COURSE (SOC) for CO and 2E

43 ECDIS - JAPAN RADIO CO

44 HAZARDOUS MATERIAL FAMILIARIZATION (HMF) for Dk Offr- Container *

45 PHOTOGRAPHS

* Delete if Not Applicable No.of days for familiarization

Joiner departed manning office with all original statutory licences and certificates and was Master is to ensure that joiners have joined with valid / original license / documents.
instructed to handcarry them onboard. prior releasing the offsigners

All documents sighted on Shore All Documents sighted Onboard

Manning Manager: Date: Master: Date:

Fleet Supdt/ Manager : Date: Stamp:

# List of Deviations Complied Date Checked by Master

Ed 01 Rev No 0
Date: 10-Jan-2020
FORM : M 09 Page 2 of 2
 PROPOSAL FOR ASSIGNMENT
If Managers forms available, same to used as and when applicable Synergy Maritime Recruitment Services Pvt Ltd.

Name of the Seafarer: Roshanbhai Subhashchandra Morekar Rank : Able Bodied Seamen Age : 35 Crew ID : 16094
Proposed to Join M.V. / M.T.: KIM OLDENDORFF Last Vessel:

Port of Joining : Date of Joining:

Years In Type : Years in Rank:

No. Checklist prior Proposal for Assignment Y / N / NA Remarks

1 Seafarer's name is not listed in the Company's "Inactive List of Seafarers"

2 Wagers and Terms& Conditions of employment agreed

Vessel specific limitations - Voyage/trade pattern, age of vessel, VISA
3
requirements, Crew Matrix, etc - considered.

4 Appraisal report from last vessel considered

5 In case of New recruit, Evaluation For Recruitment M04 completed. In case

of Promotion, Proposal for Promotion M05 completed? Any Limitations
imposed.
6 Seafarer complies with Pre Assignment Document Check list and Record M03.
Any deficiencies?

7 All documents including passport, CDC and CoC will remain valid for duration
of assignment + two month and sufficient blank pages available?

8 Flag State Licence, SIB and Endorsements as applicable are valid

Any specific requests of the Seafarer- Availability, Family Carriage, Shorter

9
contract etc

Name of PIC - Sourcing and Planning: Sign: Date:

1 All identified & any additional training as required, completed

Name of PIC - Training : Sign: Date:

No. Evaluation For Approval of Assignment Y / N / NA Remarks

For Senior Officer Assignment, Approval obtained from Principal /

1
Manager's Marine / Technical Division?

2 Staggering of relief is in compliance with Company Manual

3 Vessel Marine and Technical Superintendents informed of this crew

change

APPROVED q NOT APPROVED q

Fleet Group Head: Sign: Date:

Verified
*Signature will be done here

Verified By

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Ed 01 Rev No 0
FORM: M 06 Date : 10-Jan-2020
 US VISA CHECKLIST Synergy Maritime Recruitment Services Pvt Ltd.

NAME: Roshanbhai Subhashchandra Morekar RANK: Able Bodied Seamen

q NEW HAND q OLD HAND

q FIRST U.S. VISA q REPEAT U.S. VISA

Sl.NO. YES NO NA

1 OLD PASSPORTS ATTACHED q q q

PHOTO ON APPLICATION FORM AND PHOTO ON PASSPORT ARE DIFFERENT (PHOTO SHOULD
2
NOT BE MORE THAN 6 MONTHS OLD). USV STANDARD PHOTO.
q q q

3 PASSPORT CONDITION VERIFIED (ANY DAMAGED ETC….), SUFFICIENT BLANK PAGES. q q q

4 SIGNATURE ON PASSPORT MATCHES WITH APPLICATION FORM q q q

5 OLD SHORE PASS ATTACHED q q q

6 THE PREVIOUS US VISA, PHOTOGRAPH & NAME VERIFIED WITH PASSPORT q q q

NEW APPLICANTS - HAVE BEEN MARKED FOR U.S GOING VSL, SO THAT VSL SCHDL CAN
7
BE GIVEN FOR INTERVIEW.
q q q

8 NEW JOINER - COC, CDC & STCW'S BEEN AUTHENTICATED. q q q

9 NEW JOINERS - HAVE BEEN APPROVED BY MANAGERS (SIGNED RECRUITMENT FORM) q q q

10 HAS S'NMRY DETAILS VERIFIED (SURNAME ENDORSED. ETC…..) q q q

11 FORM VERIFIED - DATE / PORT / VSL TO JOIN ETC.. q q q

12 THE JOINING DATE IS ABOUT 2-3 WEEKS LATER THAN DATE OF APPLICATION. q q q

SL NO. OF LETTER HEAD HAS BEEN ENTERED IN REGISTER. ALL LETTER HEADS ARE
13
ACCOUNTED FOR IN SERIAL ORDER. USV NUMBER IS ALLOTTED. q q q

INTERVIEW - PERSON HAS BEEN BRIEFED THOROUGHLY FOR VISA INTERVIEW (PORT
14
JOINING/NAME, SHIP'S NAME ETC..)
q q q

INTERVIEW - NEW LETTER WITH NEW SERIAL NUMBER TO BE SENT N STANDARD

15
FORMAT.
q q q

INTERVIEW - SHIP'S NAME IS SAME AS PREVIOUS LETTER & REFERENCE IS GIVEN TO

16 q q q
PREVIOUS LETTER. DATE OF JOINING IS DEFFERED IF REQUIRED.

Manning Manager Marine Superintendent

Date:
Note: This checklist should be filed with USV letters.

Verified
*Signature will be done here

Verified By

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Rev - 0

FORM: M 20 Page 1 of 1 Date: 02 Jan 2017

 NEXT OF KIN DECLARATION Synergy Maritime Recruitment Services Pvt Ltd.

If Managers forms available, same to used as and when applicable

Name: Roshanbhai Subhashchandra Morekar Rank: Able Bodied Seamen

Joining M.V/M.T: KIM OLDENDORFF

In the event of my death / mental incapacity due to injury, during my tenure on the above
vessel.compensation payable if any, should be paid to the following person / persons as per the percentage indicated
below. My balance of wages and personal effects should be given to my next of kin whose name appears first in the
serial order.

S.No Name Address/Phone Number Relationship Proportion of Benefit

In event that the declared 'Next of Kin' is/are not alive, the nominee to receive the compensation shall be:

S.No Name Address/Phone Number Relationship

Information of Spouse, Children and Parents (If same is not mentioned above)

S.No Name Relationship Date of Birth

Signd:

Place: Date:

Witness (Name and Signature):

Note: Attach this from to Seafarer's Employment Contract

Ed 01 Rev No 0

FORM: M 07 Date: 10-Jan-2020

Page 1 of 1
 SEAFARER'S DECLARATION Synergy Maritime Recruitment Services Pvt Ltd.
If Managers forms available, same to used as and when applicable

A). Quality Policy and Drug and Alcohol Policy: As part of pre joining familiarization, i declare that i have been given access

to company's Quality policy and Drug and Alcohol policy. I hereby declare that I have read, understood and promise unreservedly

to comply with Quality Policy and Drug & Alcohol policy of Synergy Group and the Owners of the vessel, during my entire tenure

on the vessel.

B). Environmental Management System Declaration: As part of pre joining familiarization, i declare that i have been given

access to company's Environmental management system. I hereby declare that I have read, understood and promise unreservedly

to comply with the Environmental Management System of Synergy Group and the Owners of the vessel. name and contact details

of Environmental Compliance Officer (ECO) are readily available and prominently displayed on board.

C). MARPOL Declaration: As part of pre joining familiarization, i declare that i have been given access to company's manuals

and policies pertaining to MARPOL 73/78. i declare that I have read and understood company's Safety & Environment Policy and

Objectives on Environment Management System and MARPOL 73/78. I declare that I shall always comply with Company's

Environment Management System procedures which incorporates MARPOL 73/78

D). Declartion of Joining Seafarer: I hereby confirm that I have not been requested by………………………………….. (the

“Company’) or any other party acting on behalf of the company (manning agent and / or ship owner and / or manager and / or

operator and /or agent and / or master of the vessel) to pay any fees or other charges, either directly or indirectly in part or in

whole for gaining the subject employment.

The only possible costs I may be requested to bear during the recruitment process are the costs for the issuance or renewal of

my national certificate, my national seaman’s book, my passport and any other similar personal travel document, excluding the

cost of any visa which shall be paid by the ‘Company or the ship owner. I declare that I have been informed by the Company in

advance about these possible costs.

E). CBAs and Terms & Conditions: I have been given sufficient time to read the present employment agreement and Collective

Bargaining Agreement applicable to the vessel. Furthermore I declare that I have been properly informed and understood my

rights and duties and other particular conditions applicable to my duties on board, including ship owner’s policies and procedures.

F). Grievance Redressal: I have also been briefed about the company’s grevance redressal mechanism/complaint procedures

and one copy of the "Safety & Fammilirzation booklet" conatining the said procedures, has been handed over to me.

G). Duty to Report : I understand that it is my duty and I am empowered to report any violation of Quality, D&A and

Environment Protection Policy. I shall be vigilant and will report any violations of the above policies to the Master immediately

upon my becoming aware of a violation. If appropriate actions are not taken to stop the violation, I am duty bound to report this

at earliest to designated person(s) in the company.

The above declaration is truthful and I willingly sign this and without any duress.

The Seafarer: The Company:

Name: Roshanbhai Subhashchandra Morekar Name:

Rank: Able Bodied Seamen Designation:

Signature (Signature & Stamp)

Date:
Place: CHENNAI /MUMBAI / DELHI /PUNE /KOCHI /MANILA / (Specify if other location) ___________________________

Verified
*Signature will be done here

Verified By

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FORM: M 08
Ed 01 Rev No 0
Original - Seafarer File
Copy - Vessel Date :10-Jan-2020
Page 1 of 1
 PRIVATE AND CONFIDENTIAL Synergy Maritime Recruitment Services Pvt Ltd.

PERSONAL AND FAMILY DETAILS FOR PROPOSED GROUP MEDICAL INSURANCE

If Managers forms available, same to used as and when applicable

IF ANY DISCREPENCIES ARE NOTED PLEASE FILL UP THIS FORM AND SEND IT AT BELOW ADDRESS:

Email: crewinsurance@synergymanning.com

Kind Attention: Fleet Personnel Manager

Synergy Maritime Recruitment Services Pvt Ltd.
NO. 3/381, RAJIV GANDHI SALAI (OMR),
METTUKUPPAM, CHENNAI - 600 097.

TEL: +91-44-6621 5555

EMPLOYEE FULL NAME Roshanbhai Subhashchandra Morekar ADDRESS MORKER NIVAS, BALAJI PARK, TITHAL
ROAD, VALSAD – 396001. GUJARAT,
EMPLOYEE ID 16094 INDIA. VALSAD Gujarat INDIA 396001

SHIP NAME KIM OLDENDORFF

RANK Able Bodied Seamen

EMPLOYEE'S DATE OF BIRTH 06/Jan/1986 roshanmorekar@gmail.com

E-MAIL

MARITAL STATUS Married MOBILE 9586456665

FAMILY DETAILS
NAME RELATIONSHIP DATE OF BIRTH
(SPOUSE & CHILDREN )

Spouse VANSHIKA ROSHANBHAI MOREKAR Spouse 11/Nov/1959

1 st Child
FELIX ROSHANBHAI MOREKAR Son 29/Aug/2020

2 nd Child

Please note: for Group Floater Mediclaim and Personal Accident policies:
1) Please be aware that the interim additions are done once in a month and while we shall endeavor to activate individual policies at
the earliest, in some cases it may take up to a period of 5 weeks after commencement of contract. For avoidance of doubt, please do
reconfirm with us about the actual date when your policy is activated.
2) Subsequent to completion of contract, the policies shall remain valid only until the end of subsequent earned leave period

Contact details of Insurance Company,

1 . Mr. Salim Shaikh -Operations Manager
Shriissthy Insurance Service,
Mobile : +91 9987206258, +91 9892009036
Telephone : +91 22 26334291.
E-mail: salimsk09@gmail.com;
Contact details in Synergy,
2. Ms. Shefale Patra- Managing Director
crewinsurance@synergymanning.com
Shriissthy Insurance Service,
Mobile :+91 9820103003, +91 9892009036
E-mail: shefale1757@yahoo.com;
shefale@shriissthy.com

DATE:

SIGNATURE:

Verified
*Signature will be done here

Verified By
Ed 01 Rev No 0
Verified On
FORM: M10 Date: 10-Jan-2020
 Synergy Maritime Recruitment Services Pvt Ltd.
ACCOUNT DETAIL FOR ALLOTMENT

Name of Seafarer: Roshanbhai Subhashchandra Morekar

Vessel Assigned: KIM OLDENDORFF

Please remit my wage allotment request to bank account, details are as below:

Name of Beneficiary

Bank Account No.

Name of the Bank

Branch Name

IFSC Code

Postal Address of Bank

Contact Details of Beneficiary

Telephone / Mobile

Address of Beneficiary

Seafarer's Signature: Date:

Note: Any change in above Bank detail information must be infomed to Office when making the allotment request.

Original - Accounts Dept.

Copy - Seafarer file, Master, Seafarer.

Verified
*Signature will be done here

Verified By

Verified On Rev - 1

FORM: A13 Date : 02 - Jan - 17

 LETTER TO MASTER
Synergy Maritime Recruitment Services Pvt Ltd.
If Managers forms available, same to used as and when applicable

Ref. No.: SMRSPL/ Date: 08/Nov/2021

To,

The Master

M.V. / M.T. KIM OLDENDORFF

Dear Captain,

We are pleased to introduce you the following Seafarer:

Sl. No. Rank Name

1 Able Bodied Seamen Roshanbhai Subhashchandra Morekar

Joining your good Vessel at

Enclosed, Please find following documents for each Seafarer:

q Pre-Joining Medical Test Reports

q Record of Pre-Joining Familiarization
q Next of Kin Declaration M07
q Seafarer's Declaration M08
q Pre Departure Checklist M14
q Seafarers Employment Agreement M13
q Flag Licence (CRAs) or Seafarer should carry Original full term flag endorsements
q Seafarer Document Checklist and Reocrd M09
q Personal& Family Details for proposed group Medical Insurance M10
q Account Details for Allotment A13
Please ensure that the above seafarer submits the original Certificate of Competency, STCW certificates and Flag Certificate(or proof of Application)
to your custody, before you confirm Sign Off of the out going Officer/Rating.

We wish you and your staff safe and pleasant stay On Board.
Thank you.

Yours Sincerely,
For and Behalf of
Ship Owner or Owners' Authorised Representative

...........................................................

Fleet Personnel Manager

As Agents for Owners
Crew Change No. : / Mail Packet No.: /

Verified
*Signature will be done here

Verified By

Verified On

Original- Master Ed 01 Rev No 0

Copy - Office

FORM: M12 Date : 10-Jan-2020

 Synergy Maritime Recruitment Services Pvt Ltd.

GUARANTEE LETTER
If Managers forms available, same to used as and when applicable

Ref no: SMRSPL/ Date: 08/Nov/2021

TO WHOMSOEVER IT MAY CONCERN

This is to certify that the Seafarer mentioned below is travelling to join the Vessel M.V./M.T.: KIM OLDENDORFF

at on

Rank Name Passport Number Nationality

Able Bodied Seamen Roshanbhai Subhashchandra Morekar Z3330472 INDIA

The Seafarer is travelling as per the following flight schedule:

Date Flight Number Itinerary Time

He will be received by the Ship's Agent on arrival at the AIRPORT/RAILWAY STATION, who will assist them to join the
said Vessel. The Agent's full style is as follows:

In case the Seafarer is unable to join the Vessel, we guarantee that all the costs including repatriation will be bourne
by our principals.

Thankyou.
Yours Sincerely,
For and Behalf of
Ship Owner or Owners' Authorised Representative

...........................................................

Fleet Personnel Manager

As Agents for Owners
cc : Master

Verified
*Signature will be done here

Verified By

Verified On
Ed 01 Rev No 0
FORM: M11
Date : 10 - Jan - 2020
 Synergy Maritime Recruitment Services Pvt Ltd.
PRE DEPARTURE CHECKLIST
If Managers forms available, same to used as and when applicable

Name of the Officer/Crew: Roshanbhai Subhashchandra Morekar Rank: Able Bodied Seamen

Company ID No.: 16094 Date: 08/Nov/2021

Joining Vessel: KIM OLDENDORFF

This section of checklist shall be completed by the Fleet Personnel executive and shall be submitted to the Fleet Manager (Manning) before the seafarer leaves office.

1 Documentation Check Form (M31) completed, to confirm that all documents will remain valid for duration of assignment + two month. q
All ORIGINAL documents - including Passport, CDC, COC, Flag Lic., STCW certificates, Medicals- given to q
2
Seafarer. Confirmed no damage in original docs.

ORIGINAL Flag state Documents handed over to the seafarer- License, GMDSS, SSO, SIB, etc. Where application has q
3
been made, proof of application/ letter to master handed over to seafarer.

4 Pre joining Briefing completed. Check with Training division. q

5 Authentication of COC / CDC carried out for joiner available? q
6 Cadet & Junior Engineers - Cadets record Book? Progress checked by the Company q
7 Officers & Cadets - To carry uniform. Full Blues + Peak cap to be carried for New building vessels. q
8 Next of Kin Declaration Form completed. q

9 Boiler Suits (4 nos), Safety shoes, Woolen Cap, Woolen Gloves, Thermal Inner, Thermal Boiler Suit & Travel Bag q
10 Joining papers including Assignment Letter, Letter to Master, Guarantee Letter to Agent, Emergency contact numbers are received. q
11 Joiners advised to carry USD 50/INR 1500 for Immigration/Visa purpose. q
12 Air Ticket received. Visa for joining country/okay to board message checked q
13 All claims settled. NO outstanding claims will be settled on board. q
14 Collected Ship’s mail from office. q
15 Confirmed Seafarer has valid NUSI/MUI/ITF Union membership for current year. q
16 Confirmed Seafarer's data entered in e-migrate system & reference number available q
17 Approval for assignment obtained from Marine/Technical Division and owners - (where ever applicable) q

18 Confirmed Seafarer has completed all Identified Training as per Form M06 and certificates are available in Shippalm q

19 Confirmed that I have been given access to company's Quality policy and Drug and Alcohol policy, Company's EMS and MARPOL declaration q

Sign:
FPE/FPA
SEAFARER
(after completion of all formalities)

Verified By Fleet Supdt/Manager:

1
Section 2 - POST DEPARTURE - DOCUMENTATION

1 Flag Documents Applied & Uploaded - Licence q GMDSS /SSO q SIB q

All Pre Jng Docs
2 Data Entry done in Crewing Software q Seafarer Profile Updated. q q
scanned & Uploaded

3 Seafarer Signed On in Shippalm and DG E Governance and Crew List Updated. q

Crew Documentation and Software Update - Checked by FPA/FPE

Verified
*Signature will be done here

Verified By Ed 01 Rev No 0

Verified On Date: 10-Jan-2020

FORM: M 14
 Tanker Officer Matrix Compliance Check Synergy Maritime Recruitment Services Pvt Ltd.

Onboard New
Senior offficers
q Master / q CO Master / Chief Officer Master / Chief Officer Aggregate
/ q CE / q 2E
Chief Engineer / Second Engineer Chief Engineer / Second Engineer

Name:

Calendar time with Aggregate Not less than 2

Company Years

Aggregate Not less than 3

Sea time in Rank
Years

Sea time on all type Aggregate Not less than 6

of tankers Years

Minimum 2 Weeks
Between dates of joining
Date of joining
of Master and CO,
CE and 2E

Onboard New
q 2M / q 3M
Junior offficers / q 3E / q 4E Second Mate / Third Mate Second Mate / Third Mate Aggregate
Third Engineer / Fourth Engineer Third Engineer / Fourth Engineer

Name:

Aggregate Not less than 1

Sea time in Rank
Year

Sea time on all Aggregate Not less than 1

types Year

Minimum 2 Weeks
Date of joining Between dates of joining
of Master and CO,
CE and 2E

Rev - 1
FORM: M05 Date : 02 - Jan - 17
 SEAFARER'S SELF DECLARATION - BACKGROUND SECURITY CHECK Synergy Maritime Recruitment
(If Managers forms available, same to used as and when applicable) Services Pvt. Ltd.

(The Form is applicable to all new seafarers and any seafarers joining ship after gap of 12 months from his last tenure onboard ship)

1). I hereby delare that, during last 12 months, (tick as applicable)

q I had attended courses

q Worked ashore
q Other (mention reason)
Period from to

2). I hereby declare

a). That i have not, at any time during the above mentioned period immediately preceding the date of this declaration, been convicted by any court for any offence
involving moral turpitude and sentenced in respect thereof to imprisonment.

b). That no proceedings in respect of any criminal offence alleged to have been committed by me are pending before any criminal court.

c). That no warrant or summons for my appearance, and no warrant for my arrest, has been issued by a court under any law for the time being in force, and that my
departure from my country has not been prohibited by order of any such court.

Reference: (Pls mention any of your fellow seafarer)

Name:

Contact details :

The Seafarer The Company

Name : Roshanbhai Subhashchandra

Rank : Able Bodied Seamen

PP No : Z3330472

Signature (Signature & Stamp)

Verified
*Signature will be done here

Verified By
Ed 01 Rev No 0
Verified On Date : 10 - Jan - 2020
Page 1 of 1
Form : M 02
 EVALUATION FOR RECRUITMENT Synergy Maritime Recruitment Services Pvt Recruitment
Synergy Maritime Ltd.

(If Managers forms available, same to used as and when applicable) Services Pvt. Ltd.

Name of the Candidate: Ext ID : Date of interview:

Proposed Rank: Proposed to join M.V / M.T.:

Does Candidate hold Superior Certificate Yes / No / Not Applicable

Total Sea service in last rank Total Sea service in type of Vessel(s)

q Wages and Terms of Employment agreed q Certificates and Documents checked (M03) US Visa Valid Till

q Has US Visa ever been refused Yes / No If Yes, reason for refusal:
Sourcing Information:
Referred by
Last Employer Reference check with Last Employer Yes / No

Name / Contact Details of PIC from whom Info obtained

Break in sea service of more than 12 months from his/her last sign off (only for senior officer) Yes / No / Not Applicable

If yes, self-declaration background security check Form M02 to be completed by candidate

Yes / No
Was Candidate ever signed off on medical grounds:

Name of Personal Officer Sign Date

INITIAL VERIFICATION
Suitability

No INTERVIEW EVALUATION: Yes No Score / Remarks

1 CBT-Computer Based Test/CES conducted as required

2 First impression - Disposition, Health & Age

3 Mandatory STCW Courses Completed and Valid

4 Psychometric Evaluation completed as per Company policy

5 Proficiency of English / Marlin Test Conducted if required

6 Experience and past employment record

7 Record of previous Cargo carried

8 Have you previously worked with multinational workforce?If yes, What nationalities:

9 ECDIS Generic Course completed

10 ECDIS Type Specific Course completed

11 Any specific requests of the Seafarer - Availibility, Family Carriage and Shorter contract etc:

LEVEL 1 : Screening / Verification / Competency Assessment

Verified
*Signature will be done here

Ed 01 Rev No 0
Verified By
Date : 10 - Jan - 2020
Verified On Page 1 of 2
Form : M 04
 EVALUATION FOR RECRUITMENT Synergy Maritime Recruitment Services Pvt Recruitment
Synergy Maritime Ltd.

(If Managers forms available, same to used as and when applicable) Services Pvt. Ltd.

Manning Supdt / Manager Sign

LEVEL 2 : Competency Assessment / Review (Only for Senior Officers)

Manning Supdt / Manager

Sign
(Level 1 & 2 not to be conducted by the same assessor)

Training Requirements:

LEVEL 3: Enhanced Screening by Vessel Manager (Only for senior Officers)

Technical / Marine Supdt Sign

Technical / Marine Manager Sign

The candidate found SUITABLE /NOT SUITABLE for employment (strike out as applicable)
Director's Remarks, If any :

Director Sign

Verified
*Signature will be done here

Ed 01 Rev No 0
Verified By
Date : 10 - Jan - 2020
Verified On Page 2 of 2
Form : M 04
 Synergy Maritime Recruitment
PRE ASSIGNMENT DOCUMENTATION CHECKLIST AND RECORD
Services Pvt. Ltd.
(Copies of all documents must be preserved in candidate's profile)

(For new recruit - This form needs to be filled out for a candidate who has been found suitable for interview)
(For Existing crew - This form needs to be filled 60 days before planned to vessel)
Name Roshanbhai Subhashchandra Morekar Rank Able Bodied Seamen Crew Code 16094

S.No Types of Documents Number Place of Issue Date of Issue Date of expiry
1 National Passport Z3330472 SURAT 03/Nov/2015 02/Nov/2025
2 National CDC & Authentication MUM 156144 Mumbai 03/Aug/2018 02/Aug/2028
MANDATORY FOR ALL RANKS

3 National COC / COP * & Authentication DR/MMD/MUM/17080 MUMBAI 24/Nov/2009

4 EFA / MFA / Medicare * AMA2/EFA/B36/09/15 MUMBAI 02/Dec/2015 01/Dec/2020
5 PST 2040746112210549 MUMBAI 12/Aug/2021 11/Feb/2023
6 FPFF / AFF * 20407461222104018 MUMBAI 12/Aug/2021 11/Feb/2023
7 PSSR PSRU/K - 2323/2016 GUJARAT 23/Nov/2016 22/Nov/2021
8 PSCRB 20100162122128316 MUMBAI 05/Jul/2021 04/Jan/2023
9 Yellow Fever 2045 MUMBAI 30/Jan/2009 29/Jan/2029
10 MUI / NUSI / Union Membership Card *
11 INDoS No 08GL1172 MUMBAI
12 National GMDSS & Authentication
13 National GMDSS Endorsement
DECK OFFICERS

14 Radar Simulator / Ransco

15 Radar Observer / ARPA
16 BTM Course
17 SSO - Master & CO RAM/SSDS/7935 MUMBAI 28/Sep/2018 27/Sep/2023
18 Ship Manoeuvering Simulator - Master
19 ECDIS - Generic
20 HAZMAT - Container *
21 ERM Course
OFFI
ENG

22 SSO / STSDSD* RAM/SSDS/7935 MUMBAI 28/Sep/2018 27/Sep/2023

23 CoC /CoP* Endorsement. Grade/ Rank......
24 SIRB / CDC
FLAG

25 Endorsement of SSO/STSDSD
26 Endorsement of GMDSS
27 Endorsement of DCE(Oil/Chem/Gas*) Mgmt./Ops*

28 Advanced Oil/Chemical/Gas*(All officers and Engineers)

OIL/CHEM/

Basic Training Oil/Chemical/Gas*(All rating,Cadets&Trainees)

GAS*

29
30 LCHS Course - Ops/Mgmt.*

31 National DCE (Oil/Chem/Gas*) Mgmt./Ops*

32 ECDIS - Type Specific
OTHERS

33 Refresher Course (RUT)

34 Officer Safety Training (in house)

35 BTM Course - Deck Officer (in house)
36 VGP (US calling vsls)

Training needs identified Name of Courses

TRAINING NEEDS

a) As per matrix (OF-MA-013)

b) As per appraisals
c) As per interview remarks (M03) (M05)
d) As per requirement towards promotion
e) As per new legislation introduced

* Delete as applicable Number of days for familiarization

Checked by office Executive (Name) Date Signature

Verified
*Signature will be done here

Ed 01 Rev No 0
Verified By
Date : 10 - Jan - 2020
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Form : M 03
 Synergy Maritime Recruitment Services Pvt. Ltd.
APPLICATION FORM
RPSL/CHN/003 Valid till 4th July 2024

Present Rank Able Bodied Seamen Rank Applied for :

Surname : Morekar Tel No. 9586456665
Name : Roshanbhai Subhashchandra Alternate Tel
Email ID roshanmorekar@gmail.com Skype ID
Date of Birth 1986-01-06 Place of Birth MOR OLPAD SURAT GUJARAT White background. 80%
Nationality Marital Status Face
INDIA Married
Date of Availability 15/Sep/2021 Boiler Suit Size
Height(cms) 168.00 Weight(kgs) 71.00 Blood Group Shoe size
Address MORKER NIVAS, BALAJI PARK, TITHAL ROAD, VALSAD – 396001. GUJARAT, INDIA.
Nearest Airport SURAT
AADHAR for indian PAN No for Indian MUI/NUSI or any other
AWIPM4265D
Nationality Nationality Union Membership No
English Language Proficiency: Speak Read Write
Documents Number Place of issue Date of issue Date of expiry
Passport Z3330472 SURAT 03/Nov/2015 02/Aug/2028
National CDC MUMBAI 03/Aug/2018 02/Aug/2028
MUM 156144
Biometric SID
U.S. Visa C1/D
Schengen Visa
Documents Grade/level Number Issuing Authority Date of issue Date of expiry
National certificate of
Competency (COC)
CoE-Panama
CoE-Marshall
CoE-Singapore
CDC-Marshal Islands
CDC-Panama
CDC-Liberia
INDoS No 08GL1172 Government of India (IN)
STCW Certificates Number Name of MTI Date of issue Date of expiry
PSSR PSRU/K - 2323/2016 23/Nov/2016 22/Nov/2021
PSCRB 20100162122128316 04/Jan/2023
05/Jul/2021
PST 2040746112210549 12/Aug/2021 11/Feb/2023

AFF / FPFF

EFA/MFA/Medicare AMA2/EFA/B36/09/15 02/Dec/2015 01/Dec/2020

SSO/STSDSD RAM/SSDS/7935 28/Sep/2018 27/Sep/2023

High Voltage Training

National Endorsements Number Issuing Authority Date of issue Date of expiry (Where Applicable)

GMDSS

Basic/Adv Oil Endorsement

Basic/Adv Chem Endorsement

Basic/Adv Gas
Endorsement
Navigation & Main Date of expiry
Number Name of MTI Date of issue
engine Training (Where Applicable)

BTM
ECDIS - Generic

ECDIS-Type Specific I ECDIS - JAPAN RADIO CO

ECDIS-Type Specific II
I
ME Engine
RT Flex
Any Value added course/
company specific Course

Verified
*Signature will be done here

Verified By Ed 01 Rev No 0
Date : 10 - Jan - 2020
Verified On
Page 1 of 3
Form : M 01
 Synergy Maritime Recruitment Services Pvt. Ltd.
APPLICATION FORM
RPSL/CHN/003 Valid till 4th July 2024

Academic Background
Qualification Name of Institution Board/University Date of passing Grade/Percentage
PRE SEA BABA MARINE INSTITUTE 2008 PASS

Family Details - all dependent

Name Relation D.O.B Sex Passport no Place of issue Date of issue Date of Expiry
VANSHIKA ROSHANBHAI Spouse 1959-11-11 F
FELIX ROSHANBHAI Son 2020-08-29 F
Father
SUBHASHCHANDRA JAYRAMBHAI 1953-02-15 F
CHAMPABEN SUBHASHCHANDRMother 1961-06-01 F

Previous Sea Experiance (All sea service details from Cadets/Jr level. List recent vessel first)
Deck (Trade & DWT) Type of Rank Period Dates Reason for
Company's Months
Vessel's Name Engine(Type& BHP) Vessel/flag S/off
name /Days
TEU(Contaniners) From To
SHANDONGDA ZHI BULK CARRIER ANGLO Able Bodied Seamen
2020-07-29 2021-04-21 8 Months 27 Days End of Contract
AMADEUS BULK CARRIER ANGLO Able Bodied Seamen
2018-11-12 2019-08-06 8 Months 28 Days End of Contract
SHANDONG DA CHANG BULK CARRIER ANGLO Able Bodied Seamen
2017-06-10 2018-04-06 10 Months 1 Day End of Contract
ORE PARA BULK CARRIER ANGLO Able Bodied Seamen
2016-02-06 2016-10-24 8 Months 22 Days End of Contract
BALTIC BEAR BULK CARRIER ANGLO Able Bodied Seamen
2015-05-09 2015-10-11 5 Months 6 Days End of Contract
BALTIC BEAR BULK CARRIER ANGLO Ordinary Seaman 2015-01-26 2015-05-08 3 Months 13 Days End of Contract
DARYA RADHE BULK CARRIER ANGLO Ordinary Seaman 2014-01-21 2014-10-10 8 Months 23 Days End of Contract
ATLANTIC OLIVE CHEMICAL/OIL TANKER
ANGLO Ordinary Seaman 2012-12-14 2013-02-11 2 Months End of Contract
S.S.RAAHI OIL TANKER SCI Ordinary Seaman 2011-07-28 2012-04-22 9 Months End of Contract
S.S.DISHA OIL TANKER SCI Trainee Seaman 2011-06-07 2011-07-05 29 Days End of Contract
COLONEL TARAPORE OIL TANKER SCI Trainee Seaman 2009-02-23 2009-10-25 8 Months 5 Days End of Contract

Verified
*Signature will be done here

Verified By Ed 01 Rev No 0
Date : 10 - Jan - 2020
Verified On
Page 2 of 3
Form : M 01
 Synergy Maritime Recruitment Services Pvt. Ltd.
APPLICATION FORM
RPSL/CHN/003 Valid till 4th July 2024

Last Employer name PIC & Contact No / Email ID

Break in sea service of more than 12 months from last sign off: Yes/No if yes, Candidate to submit self-declaration background security check Form M02 at the time of Evaluation
Summary Of Sea goiing Experience

For all Officers: Period served on(yy/mm)

BULK CNTR OIL TNKR CHEMICAL GAS
Handymax Panama Capsize Centre-Feeder Cntr >8000 Cntr >14000 Prod. Tanker Aframax VLCC Oil& Chem Parcel Gas
x

For Engineer Officers only: Period served on (yy/mm)

Sulzer B&W MAN Pielstick UEC Doxford Steam UMS CPP Cranes MAK/ 4-Stroke ME B/C

Pump Experience (In months) for All Tanker Seafarers

FRAMO COP

Have you been on board vessels during Drydocking Yes/No If Yes, In Which Rank New Construction Yes/No If Yes, In Which
Rank
Have you been on involved in any Incidents of Grounding / Fire / Explosion / Collision / Abandon Ship / Rescue / Major
Oil pollotion / Drug Smuggling / Towed or Towning another vessel. If Yes, Please Specify
Have you been involved in a court of Enquiry for a Maritime accident ? If yes, Please specify
Have you ever been involved in a criminal case : If yes on any of the above, give details:
Have you present or previous certificate ever been suspended/revoked? If yes, give details:
Do you suffer or have sufferred from : Diabetes/High Blood pressure/Hepatitis/Epilepsy/Nervous Disorders/ Distributed
Vision Or Hearing/Vertigo If Yes, give details:
Are you a habitual user of Drugs / Narcotics / Excessive Alcohol. If Yes, give details:
Have you previously worked with multinational workforce ? If yes, What nationalities:

Declaration by the Applicant:

I understand that a strict medical examination including Drug and 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 medical officer is final.
I declare that there are no criminal/police investigations in progress against me.
I confirm that all my travel documents are valid and in order. I understand that if my travel Documents become invalid or restricted at any time during the course of my employment and
cannot be revalidated by me under normal process, the contract of employment will terminate and all costs repatriation will be borne by me.
I am/ am not presently employed elsewhere.
I am awarw that Synergy Maritime Recruitment Services Pvt Ltd., does not have any agents in india for employing Seafarers.
If my application is successful, I will be available to report at your office on or after:______________________

If this application sent through candidate's email id, applicant's signature is not required. Candidate should submit the signed application form during the evaluation process/PJF

Name of Applicant Date Signature of the Applicant

Verified
*Signature will be done here

Verified By Ed 01 Rev No 0
Date : 10 - Jan - 2020
Verified On
Page 3 of 3
Form : M 01