APPLICATION FORM
PERSONAL DATA
Surname: MONDAL
Middle Name: KUMAR
First Name: BIKASH
Nationality: INDIAN
Date of Birth: 05-09-1965
Place of Birth: BARASAT
Post Applied for:2nd Engineer
Willing to Accept Lower Rank? Yes / No: NO
Available from: ( 23 /02 / 2018 )
Permanent Address:
Present Address:
TULSI BAGAN, P.O.: BIRATI, KOLKATA,
W.B., PIN Code: 700051
SAME AS PERMANENT ADDRESS
Tel No / Mobile No.: 983-***-****
Tel No / Mobile No.:
Email ID : ********.******@*****.***
Passport No.
Date of issue
Place of Issue
Date of Exp.
ECNR
Blank Pages
K0477215
30-03-2012
KOLKATA
29-03-2022
ECNR
33
US VISA
MCV TRN No
MUI M’ship#
Australian MCV
Seaman’s Book(CDC)
Number
Date of Issue
Place of Issue
Expiry Date
Remark
Indian
BY67324
09-10-1992
MUMBAI
23-04-2025
Liberian
Others
INDOS
00EL1590
LBS, MUMBAI
Licence
Grade
Number
Date of Issue
Pl. Of Issue
Expiry Date
Indian
CLASS IV
95Z-0274
21-12-2015
KOLKATA
06-11-2020
Liberian
Panamanian
UK
Others HONDURAS
Class 2
RH-A No 043021
22-02-2018
Honduras
22-02-2022
Civil Status : Single / Married / Separated / Divorced / Widowed
MARRIED
Full Name of Next of Kin : MRS. POLY MONDAL
Relationship : WIFE
Address of Next of Kin : SAME PERMANENT ADDRESS
Tel. No. : 086********
Family Data
Name
DOB
PPT No.
DOI
Place of Issue
DOE
ECNR
Wife
MRS. POLY MONDAL
21-01-1969
Child M/F
MS. TIYASA MONDAL
13-04-2000
Child M/F
MS. DISHA MONDAL
12-12-2013
Details of Courses & Certificates
Number
Dt. Of Issue
Dt. Of Expiry
Pl. Of Issue
Issued by
Advance/Basic Fire Fighting
00190
26-11-13
25-11-2018
KOLKATA
IMU KOLKATA
Proficiency in Survival Craft/Rescue Boat/PST/PSC RB Upgradation
00178
16-11-2013
15-11-2018
KOLKATA
IMU KOLKATA
Elementary/Medical First Aid/Medicare
0048
18-11-2013
17-11-2018
KOLKATA
IMU KOLKATA
Personal Safety &Social Responsibility (PSSR)
02712
12-02-2015
KOLKATA
IMU KOLKATA
Ship Security Officer Course
02668
09-11-2013
KOLKATA
IMU KOLKATA
Radar Observer / ROP
ARPA
Radar Simulator (RANSCO)
LCHS Management/Operational
High Voltage Safety and Switch Gear Course
SMCC/HVO/449
03-04-2017
KOLKATA
SEACOM MARINE COLLEGE
TASCO
KOL/TASCO/11-17/08
17/11/2017
KOLKATA
SEI Educational Trust,KOL
GMDSS
Petroleum Tanker Safety
Chemical /Gas Tanker Safety
Petroleum Tanker Fam.
Chem/Gas Tanker Fam.
Ship Manoeuvring Simulator
ECDIS
Bridge Team Management
Bridge Resource Mgt.
Eng Room Resou Mgt.
Eng Room Team Mgt.
Eng Room Simulator
Dangerous Cargo Endorsements
Grade/ Level I/II
Number
Date of Issue
Place of Issue
Dt. Of Exp.
OIL TANKER
I
DCE01KOL17001233
23/11/17
KOLKATA
22/11/2022
Pre Sea Training / Apprenticeship
Name of Institute / College
HINDUSTANSHIPYARD LTD., VIJAG
From
05-08-1991
To
04-08-1992
Type of Degree
I hereby afirm that all the information provided by me in this application is true and correct tothe best of my knowledge and belief, that no Certificate of competency or licence issued to me has ever been Revoked or Suspended.
Date 23/02/2018 Rank 3E
Previous Sea Service ( Date Commencing from Last Vessel)
Sr. No.
Name of Owners / Managers
Name of Vessel
Rank
Flag
Type
DWT
GRT
BHP
Engine Type
UMS
Y/N
From
To
Total
MM/DD
Reason
for S/Off
1
OESM/TWSM
M.V. SSL BHARAT
3E
IND
CONTAINER
34704
29383
30560
MAN B&W 8S 70MC
N
06-07-2017
26-01-2017
06/21
2
APJ SHIPPING LTD.
MV APJ KAIS
3E
IND
BLK
32957
9480
MAN B&W 6S50MC-C
N
19-02-2016
19-04-2016
02
3
OESM
MV SSL SAGARMALA
3E
IND
CONTAINER
9336
6942
6820
MAN B&W6L42MC
N
17-04-2015
15-10-2015
05/29
4
OESM
MV OEL BENGAL
3E
S’PORE
CONTAINER
14910
10676
8340
MAN B&W50MC
N
18-06-2014
01-01-2015
06/14
5
OESM
MV OEL KOCHI
3E
IND
CONTAINER
24553
21339
16680
MAN B&W
6S60MC
Y
01-08-12
31-01-13
06/00
6
OESM
MV JINDAL KAMLA
2E
IND
GC/
CONTAINER
5847
2480
MWM-AG TBD510BL8
N
29-05-11
15-09-11
03/17
7
BSM
MV PACIFIC RUBY
3E
HONG KONG
VLOC
254095
147902
25181
MAN B&W
7L90MC
Y
29-11-09
02-05-10
05/04
8
ESM
MT LYRA PIONEER
3E
PANAMA
OILP
45985
28059
12890
MAN B&W
6S50MCC
N
20-12-08
14-06-09
05/24
9
ESM
MV VANDA
COLOSSUS
3E
S’PORE
BLK
55863
30882
8200
MAN B&W
6S50MCC
Y
03-03-08
15-09-08
06/12
10
ESM
MV MOKARA
COLOSSUS
3E
S’PORE
BLK
55781
30807
8200
MAN B&W
6S50MCC
Y
28-11-06
11-07-07
08/13
11
ESM
MT PACIFIC
OASIS
3E
PANAMA
OILP
28799
12899
MAN B&W
6S50MCC
N
05-02-06
30-06-06
04/26
12
FML
MT DEVSI
3E
IND
TANKER
52629
14700
B&W
6L70MCE
N
24-12-04
13-08-05
07/19
13
FML
MV MIN NOBLE
3E
PANAMA
BLK
65785
35671
14400
SULZER
6RND76M
N
08-07-03
10-02-04
07/02
14
FML
MV NEW ERA
3E
HONG KONG
BLK
17590
10303
MITSUBISHI
5EUC52LS
N
06-07-01
17-01-02
06/01
15
SCI
MV DEV PRAYAG
3E
IND
BLK
28739
10800
B&W
6L60MCE
N
11-08-98
14-07-99
11/03
16
SCI
MT
CV RAMAN
3E
IND
TANKER
25040
9900
SULZER
6RND68
N
16-05-96
06-02-97
08/20
17
SCI
MV HARGOBIND
4E
IND
BLK
23339
13100
B&W
7K74EF
N
02-05-94
13-05-95
13/11
18
SCI
MV VISVA
SHOBHA
5E
IND
GC
9337
9000
SULZER
6RD76
N
14-10-92
12-11-93
12/28