Medical C

Form # **-*/* (Issue * Rev *) Page * of *

APPLICATION FORM

SECTION I

Rank Applied

Chief Officer

Date of Availability

DD-MMM-YYYY

**-***-****

SECTION II Personal Details

Last Name/Surname TIN MIN HTUN

First Name

Name as per passport TIN MIN HTUN

Date of Birth

11.02.1972 Place of Birth: MOGAUNG

Nationality

MYANMAR

Marital / Civil Status

Single X Married Divorced Separated

INDOS No(for Indians)

Permanent Address

NO.31, 6FLOOR,UPHEE STREET,SANCHAUNG TOWNSHIP,YANGON,MYANMAR. Present Address

(if different from

permanent add)

SAME AS ABOVE

Home Principal Airport YANGON INTERNATIONAL AIR PORT Contact Number

( Mobile )

+95-95164681

Tel

Alternate Tel,+95-925*******

Email

***********@*****.*** Skype ID:+95-95164681

Height (in cms) 168 cm Weight (in kgs) 71 Kg

Boiler Suit Size L Shoe Size 42

SECTION III

Travel Documents

Doc Number Issue Date Place of Issue Expiry Date

Passport MB983069 09 FEB 2017 YANGON,MYANMAR 08 FEB 2022 Seaman Book 45640 31 AUG 2017 YANGON,MYANMAR 30 AUG 2027 USA Visa C1/D

Aust MCV

Yellow Fever 15 NOV 2012 YANGON,MYANMAR 15 NOV 2022 SEAFARER RECRUITMENT & PLACEMENT SERVICE OFFICE

APPLI

CA

NT’S PHOTO (photo is a

must )

less than 18 yrs not eligible

Form # 07-5/5 (Issue 1 Rev 1) Page 2 of 4

SECTION IV

Pre-Sea Training / Apprenticeship Details

Name of Institute From To Type of Degree/Certification Obtained SECTION V Certificate of Competency Held (valid)

Class / Grade Issuing

Country

Certificate No Date Issued Expiry Date

CLASS II MYANMAR 2DK002641 19 APR 2018

24 NOV 2020

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 AFF DMA,MYANMAR 19 APR 2018 2DK002641 24 NOV 2020

PSCRB DMA,MYANMAR 19 APR 2018 2DK002641 24 NOV 2020 Med FAID /

Medicare

( as applicable)

DMA,MYANMAR 19 APR 2018 2DK002641 24 NOV 2020

PSSR DMA,MYANMAR 19 APR 2018 2DK002641 24 NOV 2020 ARPA DMA,MYANMAR 19 APR 2018 2DK002641 24 NOV 2020 RANSO

GMDSS DMA,MYANMAR 19 APR 2018 2DK002641 24 NOV 2020 HAZMAT

ECDIS DMA,MYANMAR 19 APR 2018 2DK002641 24 NOV 2020 SHIP SECURITY

OFFICER (SSO)

DMA,MYANMAR 19 APR 2018 2DK002641 24 NOV 2020

SHIP HANDLING

SIMULATOR

ENGINE

HANDLING

SIMULATOR

SECTION VIII Medical History

Yes No

Have you ever signed off a ship due medical reason? NO Have you undergone any medical operations in the past? NO Have you consulted a doctor during the past 12 months for an illness / accident? NO Do you have any health or disability problems now? NO If answer to any of the above is YES then give further details below or on a separate sheet of paper Name of Applicant: TIN MIN HTUN

Form # 07-5/5 (Issue 1 Rev 1) Page 3 of 4

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)

MV NORTHERN

VOLITION

UNITEAM CONTAINER 274**-****-***** 2/0 21.09.2017 23.12.2017 E.O.C MV NORTHERN

VOLITION

NUNITEAM CONTAINER 274**-****-***** 2/0 06.05.2017 23.08.2017 E.O.C MV NORTHERN

VOLITION

UNITEAM CONTAINER 274**-****-***** 3/0 09.03.2017 05.05.2017 E.O.C MV NORTHERN

ENDEAVOUR

UNITEAM CONTAINER 257**-****-***** 2/0 23.07.2013 13.01.2014 E.O.C MV NORTHERN

ENDEAVOUR

UNITEAM CONTAINER 257**-****-***** 2/0 17.11.2012 18.05.2013 E.O.C MV X-PRESS

MAKALU

UNITEAM CONTAINER 360**-****-***** 2/0 04.05.2012 31.07.2012 E.O.C MV CSAV

RANCO

UNITEAM CONTAINER 360**-****-***** 2/0 24.10.2011 04.05.2012 E.O.C MV APL

MALAYSIA

UNITEAM CONTAINER 544**-****-***** 2/0 22.03.2011 05.08.2011 E.O.C MV APL

MALAYSIA

UNITEAM CONTAINER 544**-****-***** 3/0 04.11.2010 22.03.2011 E.O.C MV NORTHERN

DIPLOMAT

UNITEAM CONTAINER 360**-****-***** 3/0 23.08.2009 02.07.2010 E.O.C MV NORTHERN

ENDEAVOUR

UNITEAM CONTAINER 274**-****-***** 3/0 30.06.2008 25.03.2009 E.O.C MV CAP FRIO UNITEAM CONTAINER 274**-****-***** 4/0 03.05.2008 30.06.2008 E.O.C MV

LUETJENBURG

UNITEAM CONTAINER 37323 3700 OS 21.02.2005 12.03.2006 E.O.C MV MSC LISA UNITEAM CONTAINER 54304

5400 OS 15.05.2004 06.10.2004 E.O.C

MV P&O

NEDLLOYD

DAMIETTA

UNITEAM CONTAINER 36606 3600 S-DC 23.11.2002 28.11.2003 E.O.C Name of Applicant:

Form # 07-5/5 (Issue 1 Rev 0) Page 4 of 4

SECTION IX GENERAL

Yes No

Have you ever been the subject of a court of enquiry or involved in a maritime accident? NO Have you ever had a professional licence suspended or revoked NO 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 Family Data (Spouse & Children only)

Sr No First Name Relationship Date of Birth

1 DAW MYINT MYINT HTAY WIFE 05.05.1968

2 MG AUNG KHANT MIN SON 21.08.2005

3

4

Minimum 2 references of fellow seafarers preferably sr. ranks presently sailing with other Company Sr No Name of Seafarer Rank Contact Details

1 AUNG TIN MOE MASTER +95-9-452030553

2 ZAW MIN OO MASTER +95-9-254531690

3

Declaration :

I confirm that the validity of all above mentioned documents covers the contract duration + 3mnths. 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: TIN MIN HTUN Signed: Date: 20.07.2018 Note: - Please note that company does not charge any recruitment fees for providing employment or for any processing fees for on-boarding.

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