APPLICATION FORM AFFIX HERE

YOUR RECENT

PASSPORT

SIZE

PHOTOGRAPH

Post applied for : AB Willing to accept lower rank? Available From: 22

Yes / No /04 / 2014

1. Personal Details

First Name: PRAMOD Middle Name : Last Name / Surname : DUBEY

SHAMNARAYAN

Nationality: INDIAN Date of Birth : Place of Birth : MUMBAI

10/08/1987

Permanent Address- 1/11, EBRAHIM COURT Present Address- 1/11, EBRAHIM COURT

BLDG, ST. PAUL STREET, HINDMATA, BLDG, ST. PAUL STREET, HINDMATA,

DADAR-EAST DADAR-EAST

City MUMBAI City MUMBAI

Pin 400014 Pin 400014

Tel: 808-***-**** / 986-***-**** Tel: 808-***-**** / 986-***-****

E mail: aced3y@r.postjobfree.com E mail: aced3y@r.postjobfree.com

Nearest Airport : Mumbai / New Delhi /

Chennai / Kolkata

Document Country No. Issued Place Valid

Until

Passport INDIA H3261113 INDIA MUMBAI 28TH

DEC2018

Seamen's Book Liberian

Seamen's Book Marshall

islands

Seamen's Book Panamanian

Seamen's Book Other:

Seamen's Book INDIAN MUM-155685 INDIA MUMBAI 21ST OCT

2018

Seamen Registration No: Indos No. 08GL0524 ECNR : Yes / No.

200*********

US visa - "C1" / "D"

Yes/ No

Name of Nominee SUVEENA PRAMOD DUBEY Relation: WIFE

In case of fatality :

Address 1/11, EBRAHIM COURT BLDG, ST. PAUL STREET, HINDMATA, DADAR-EAST,

MUMBAI

City

Pin : 400014 Tel: 808-***-****

Family Details

Relations First Name Last Name Date of Passport Issued Place Valid

hip Birth No. Until

Wife SUVEENA DUBEY 04/09/198

6

Child M/F

Child M/F

Child M/F

Child M/F

Indicate the type of valid visa* USA CANADA

BRAZIL UK OTHERS MALAYSIA

Height ( In cms ) 175 Weight (In Kgs) Shoe Size : 10 Boiler Suit Size :

72 42

2. Certificates / Courses

A. Academic Year of Highest Qualification attained Class

Qualification Passing

School / College

Shridhar University 2013 TYBcom 1st Class

Cosmopolitant maritime 2009 G.P.Rating 1st Class

collage

B. Training / From To Institution / University

Apprenticeship

C.Highest Competency Certificate Held

Issuing Authority : Grade Certificatio Date Place Valid

n No. Issued Issued Until

National (Country) 1st Class G0806M05028/ Jan 2008 Chennai Jan 2018

India June08/13934

Liberian

Panamanian

Marshall Island

Cayman Island

Hong Kong

Cyprus

D. Dangerous Cargo Certification

1. Endorsement on NATIONAL Number Date Place Issued Valid

Certificate Issued Until

Petroleum

Liquefied Gas

Liquid Chemicals

E. Dangerous Cargo Endorsement ( Issued by Countries other than in Section

2D)

Country Type @ Capacity # Certificate Date Issued Valid Until

No.

Use following nomenclature: "Tanker man person in charge", " Tanker

man assistant" @- Petroleum / Chemical

F. Watch Keeping Certificate: (For Ratings Only) (Include Liberian Special

Qualification) :

Certificate to work as ( e Certificate Date Issued Place Issued Valid

.g. AB/ Oiler) No. Until

NWKO ( AB ) DR/MMD/MUM/1 12/02/2010 Chennai Life time

7404

G. Courses Attended and Certificates Obtained

Course / Certificates Certificate Date Institution / Valid

Number Issued Place Issued Until

Advanced fire fighting

Fire Prevention & Fire FPFF/GB13/28 26/04/200 Chennai Life time

Fighting 8

Proficiency In Survival

Craft [PSCRB]

Personal Survival PST/GB13/28 19/05/200 Chennai Life time

Techniques 8

Medical First Aid / EFA/GB13/28 9/05/2008 Chennai Life time

Elementary First Aid

Ship Captain Medical

(Medicare)

Personal Safety and & PSSR/GB13/28 05/5/2008 Chennai Life time

Social Responsibility

Specialized Training Prog.

(Petroleum)

Specialized Training Prog.

(Chemical)

Specialized Training Prog.

(Gas)

Oil Tanker Familiarization

Radar Observer

ARPA / RANSCO

Restricted Radio Telephony

Radar maintenance

Electro. Tech. Officer(

ETO)

Engine simulator

Ship Handling Simulator

E.N.E.M

GMDSS

AMOS-D/PMS

C.O.C Revalidation / Up

gradation

Yellow fever 2043 12/02/200 Mumbai 12/02/201

9 9

Other ( Specify )

3. General:

A. Have you ever been denied a foreign Visa? Yes / No.

If yes, state which Country and reason ( If known ) :

B. have you been the subject to court of enquiry or involved in a maritime

accident ? Yes / No.

If yes, pl attach the details

C. References: (Please give references from 2 recent employers who we may

contact for references.)

Name of Company

Name of Person to Contact

Telephone

For Office Use Only

Company Vessel Type DWT/GRT Main Engine Type BHP/TEU Rank Date from

Date To Period Chkd SEVEN SEAS SHIPPING CO.

Meu Teck No-3 General Cargo 15000 Fait 1500 OS 27/2/09 3/12/09 1

YRS

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