APPLICATION FORM

SECTION I

Applicant Name ( As per passport )

MOIN AHMED

Rank Applied

2ND ENGINEER

Date of Availability

END OF DEC, 2017

SECTION II

Personal Details

Family Name/Surname

AHMED

First Name/Given Name

MOIN

Date of Birth

(less than 18 yrs not eligible to apply)

25.12.1969 Place of Birth : BARISAL, BANGLADESH

Nationality

BANGLADESHI

Marital / Civil Status

Single Married Divorced Separated

INDOS No(for Indians)

Permanent Address

FLAT NO-602, 5TH FLOOR, 165/E TEJKUNIPARA, TEJGAON, DHAKA-1215, BANGLADESH,

Present Address

(if different from permanent add)

12/KHA, SIDDESHORI SUDI SOMAJ GOLLI, FLAT-A4, SIDDESHORI, DHAKA-1217, BANGLADESH.

Home Principal Airport

DHAKA

Contact Number

Tel

+880-1706-612598

Mobile

+880-1717-703234 (self)

Email

ac4ce2@r.postjobfree.com Skype ID:

Height (in cms)

1.61M Weight (in kgs) 77kg

Boiler Suit Size

XL Shoe Size 42

SECTION III

Travel Documents

Doc Number

Issue Date

Place of Issue

Expiry Date

Passport

BL0636983

24.01.2012

DHAKA

19.08.2021

Seaman Book

C/O/2480

13.12.2017

CHITTAGONG

12.12.2027

USA Visa C1/D

KD254739

18.01.2016

DHAKA

13.03.2021

Aus. MCV

144*******

28.01.2016

MGPC, BRISBANE

28.01.2019

Yellow Fever

VALID

SECTION IV

Pre-Sea Training / Apprenticeship Details

Name of Institute

From

To

Type of Degree/Certification Obtained

BANGLADESH MARINE FISHERIES ACADEMY.

1987

1990

PRE-SEA TRAINING (1ST CLASS)

SYDNEY INSTITUTE OF TECHNOLOGY

2002

2003

DIPLOMA OF MARINE ENGINEERING

SECTION V

Certificate of Competency Held (valid)

Class / Grade

Issuing Country

Certificate No

Date Issued

Expiry Date

Class-2 (Motor)

AUSTRALIA

AY18116

22.12.2016

31.12.2021

SECTION VI

Certificate of Endorsement Held (valid)

Class / Grade

Issuing Country

Certificate No

Date Issued

Expiry Date

SECTION VII

Courses Attended and Certificates Obtained

Name of Course/Certificate

Institute

Place

Issue Date

Certificate No.

Expiry Date

Personal Survival Technique

CMC, CHENNAI

CHENNAI

28.10.16

CMC/PSCRB/2016/819/07

28.10.2021

PSC&RB

CMC, CHENNAI

CHENNAI

28.10.16

CMC/PSCRB/2016/819/07

28.10.2021

PSSR

IIMT, BANGLADESH

DHAKA

16.01.2016

PSSR/160/11

24.03.2021

Advance Fire Fighting/ FPFF

CMC, CHENNAI

CHENNAI

27.10.16

CMC/RAFF/2016/641/14

28.10.2021

Medical Care/Medical First Aid/ Elementary First Aid

CMC, CHENNAI

CHENNAI

24.10.16

CMC/RMFA/2016/B57/05

23.10.2021

Security Awareness Training

PMA, CHENNAI

CHENNAI

26.10.2016

BDSAT-2210

UNLIMITED

Designated Security Duties

PMA, CHENNAI

CHENNAI

26.10.2016

BDSAT-2210

UNLIMITED

HIGH VOLTAGE & SWITCH GEAR COURSE

SEACOM MARINE COLLEGE

CALCUTTA

17.10.2016

SMCC/HV/109

UNLIMITED

ERM & APPLICATION OF LEADERSHIP AND MANAGERIAL SKILL

IIMT, BANGLADESH

DHAKA

14.11.2016

EMRL MS/1614/12

UNLIMITED

SECTION VIII

Medical History

Yes

No

Have I ever signed off a ship due medical reason?

Have I undergone any medical operations in the past?

Have I consulted a doctor during the past 12 months for an illness / accident?

Do you have any health or disability problems now?

If answer to any of the above is YES then give further details below or on a separate sheet of paper

MEDICAL VALID UPTO 13-12- 2019. ISSUED BY PORT HEALTH AUTHORITY, CHITTAGONG, BANGLASDESH

Name of Applicant: MOIN AHMED

Vessel Name

Company

Vessel Type

GRT

TEU

(Contr)

Engine Make &Type (in full)

BHP

Rank

S/on Date

S/off Date

Remarks

(For short tours)

M.V SHAGANG HONGFA

PIL, SINGAPORE

BULK

93228

HYANDI ID 2SA 6 CY

18660

2/E

22-01-17

01-06-17

EOC

M.V TONG AN CHENG

PIL, SINGAPORE

MULTIPURPOSE

18198

DMD MAN B&W 6S50 MC-C

9960 KW

2/E

24-01-16

23-07-16

EOC

MV. KOTA NALURI

PIL, SINGAPORE

CONT

DMD MAN B&W 7S60 MC-C

16660 KW

2/E

04.06.15

09.10.15

EOC

MV. CS CALVINA

CAMPBELL SHIPPING CO LTD

BULK

24065

WARTSILA 6RTA 48T

7368KW

2/E

31.07.14

21.01.15

EOC

MT. CLAYTON II

PHP SHIPPING LINES

TANKER

2843

AKASAKA DILES ENGINE

3300

C/E

26.08.12

05.04.13

EOC

MV. BASHUNDHARA-2

SYMPHONY SHIP MANAGEMEN

BULK

27535

SULZER 7RD68

9100

2/E

15.04.12

26.07.12

EOC

MV. MEGHNA PRIDE

MERCANTILE SHIPPING LINES

BULK

30928

SULZER 6RTA 62U

8670KW

2/E

09.12.10

15.12.11

EOC

MV. AMSIR

MERCANTILE SHIPPING LINES

BULK

36554

MITSUBISHI SULZER 6RTA62

12900

2/E

22.07.10

09.11.10

EOC

MV. OCEAN PROBE

V. SHIPS MANAGEMENT

CONT

15095

MITSUBISULZER

9950

2/E

23.02.10

18.05.10

EOC

MV. SARWAR JAHAN

BRAVE ROYAL SHIPMGNT

BULK

23186

SULZER 6RTA58

6950KW

2/E

09.07.09

28.10.09

EOC

MV. CUSTODIA ATHENA

BRAVE ROYAL SHIPMGNT

BULK

23186

MITSUBISHI SULZER 6RTA62

6950KW

2/E

02.05.09

08.07.09

Vsl name changed

MV. OCEAN PRELUDE

V. SHIPS MANAGEMENT

BULK

36097

MITSUBISHI SULZER 6RTA62

1350

2/E

18.03.08

02.11.08

EOC

MV. KHALEDA

AL- UNITED MARITIME

G.C

15927

SULZER 7RND 68

11600

2/E

25.01.07

30.10.07

EOC

MV. CONTINENT-4 /

MV. EID-A-MOSTAFA

CONTINENTAL LINER AGENCY

G.C

13605

MAN B&W DE8545HO

4400

2/E

31.01.06

08.11.06

EOC

MV. IRAN SHOJAAT

IRAN SHIPPING LINES

BULK

12124

SULZERBHP 7RND 68

3000KW

4/E

26.10.99

18.07.00

EOC

MV. CHAMRAN

IRAN SHIPPING LINES

BULK

25768

B&W 6l6OMC

11500

4/E

28.08.98

10.04.99

EOC

MT. FATEHA

BIRDS BANGLADESH

TANK

608

DIHATSU, BHP

1300

4/E

31.05.98

30.06.98

TF

MV. SINTRA

PIL SINGAPORE

CONT

6394

PILESTICK VTYPE

6000

4/E

15.08.97

25.12.97

EOC

MV. AEGEAN SEA-1

QC SHIPPING LINES LTD

BULK

9606

IHI SULZER

7200

4/E

16.06.96

06.03.97

EOC

MV. QC TEAL

QC SHIPPING LINES LTD

CONT

5100

MAK6M551

3200

4/E

25.04.96

16.05.96

Family Prob

MV. GOLDEN FISH

AL- UNITED MARITIME

G.C

10244

AKASAKA MITSUBISHI6UEC 65/135 C

8100

E.CDT

22.07.93

04.01.95

EOC

MV. TRANS AMERICA

TRANS ASIA LTD

G.C

5000

AKASAKA MITSUBISHI 4 STROKE.6DH51SS/BHP

3000

E.CDT

30.11.92

28.02.93

Mgmt Decision

Name of Applicant: MOIN AHMED, Rank experience 79 months 22 days

SECTION IX

GENERAL

Yes

No

Have I ever been the subject of a court of enquiry or involved in a maritime accident?

Have I ever had a professional licence suspended or revoked

If yes to any of the above then please give full details below or on a separate sheet of paper

Any other information you wish to add in support of your application

WORKED AS A CHIEF ENGINEERING INSTRUCTOR IN NATIONAL MARITIME INSTITUTE, CHITTAGONG BANGFLADES. ( 2014-2015)

Family Data (Spouse & Children only)

Sr No

First Name

Relationship

Date of Birth

1

ASMA YEASMIN

WIFE

01.01.1980

2

TASMIA AHMED

DAUGHTER

13.07.2003

Minimum 2 references of name of person in charge with designation and contact in 2 previous companies

Name of Company

Name of Person in Charge

Designation

Contact Details

CAMPBELL SHIPPING CO LTD

Mr Rajesh Kandaria,

(SR.TECH SUPER)

+91-976*******

MASS MARINE AGENCY

MR. KHALED

GENERAL MANAGER

+880**********

Declaration:

I confirm that the validity of all above mentioned documents covers the contract duration + 3 months and + 6 months for passport.

I hereby certify that the information given in my application form including sea service details are true and complete to the best of my knowledge. I agree my understanding that if employed by PIL, any false or incomplete statement on this application and submitted document will lead to my dismissal from the employment without notice or pay-in-lieu.

Name of Applicant: MOIN AHMED

Signed:

Contact this candidate