Obj***

PHOTO

APPLICATION FORM

PERSONAL DATA

First Name :GAGAN Middle Name :PREET Surname : SINGH

Nationality :INDIAN Date / Place of Birth :31/05/1992 Available From:

SAMBALPUR,ORRISA IMMEDIATE

Post Applied For : G.P RATING Willing to Accept Lower Rank: YES Last drawn wages :

Permanent Address: prospect Present Address:

#1102 GURU ARJUN NAGAR, JAGADHARI #1102 GURU ARJUN NAGAR, JAGADHARI

PIN: 135003 DISTT. YAMUNA NAGAR, PIN: 135003 DISTT. YAMUNA NAGAR,

HARYANA. HARYANA

Phone No: 954*******

Email: acos78@r.postjobfree.com acos78@r.postjobfree.com

TRAVEL DOCUMENTS DETAILS :

Place of Date of Minimum 4

Passport No: Date of Issue ECNR

Issue Expiry Blank Pages

K9019933 31/1/2013 CHANDIGA 30/1/2023 CLEAR YES

RH

U.S. VISA NA NA NA NA NA

C1/D No.:

Seaman’s Book (CDC) Number Date of Issue Place of Issue Expiry Date

Indian MUM 231126 28/02/2014 MMD, MUMBAI 27/02/2024

Panamanian

NEXT OF KIN DETAILS:

Full Name of Next of Kin: GURMEET SINGH Relationship: BROTHER

Address of Next of Kin: #F166 VISHNU GARDEN, NEW DELHI

Phone STD Code: Phone No.:+91-921*******

BANK ACCOUNT DETAILS :

Account Holder’s Name : HARINDERJEET SINGH

Name Of Bank & Account No. : STATE BANK Branch & Address: YAMUNA NAGAR

OF INDIA

Yamuna Nagar(Haryana) 135003

A/CNO. 201********-**** guru Arjun nagar, jagadhri

Family Place of

Name D.O.B PPT.No. D.O.I D.O.E

Details Issue

1 HARINDER 19/10/1968

SINGH

2 BHUPNDE 06/09/1969

R KAUR

3 KHUSHME 22/12/1995

ET KAUR

Height : 176 CMS Weight : 70 KG

Shoe Size 8”

Boiler Suit Size XL

DETAILS OF COURSES & CERTIFICATES :

STCW Number Date of Issue Date of Issued by

Courses: Expiry

PSDS PSDS R7/12/13 12/11/2013 UNLIMITE IMA CHENNAI

D

PSSR PSSR R7/12/13 21/08/2013 UNLIMITE IMA CHENNAI

D

PST PST R7/12/13 13/08/2013 UNLIMITE IMA CHENNAI

D

FPFF FPFF R7/12/13 08/08/2013 UNLIMITE IMA CHENNAI

D

EFA EFA R7/12/13 17/08/2013 UNLIMITE IMA CHENNAI

D

OTFC OTFC R7/12/13 OTFC R7/12/13 UNLIMITE IMA CHENNAI

D

Others:

Yellow Fever

INDOS NO : 13GL3988 04/09/2013 UNLIMITE LBS-CAMSAR MUMBAI

D

Previous Sea Service (Commencing from Last Vessel) (PLEASE FILL THE GRT AS

PER STCW REQUIREMENT)

Name of GRT /

Sr.No. Name of Vessel Type Rank From To

Company DWT

MEDICAL HISTORY

Have you ever signed off from a ship due to Medical reasons, NO

( If Yes give details)

Name of Vessels Date of Occurrence

Brief Description of Illness / Injury/ Accident

(b) Did you suffer or Are you Presently suffering from any Disease likely to render you NO

unfit for Service at Sea or likely to endanger the health of others on board.

(c) Are you addicted to alcohol or drugs of any kind. NO

(d) Have you suffered from following

Malaria NO Diabetes NO Epilepsy NO Nervous Disability NO

(e) Did you ever undergo psychiatric treatment : NO

REFERENCE

Sr. Name of the company PIC Designation

No

1 Can be provided If required

1. The foregoing details are true and accurate and complete

2. There are no contractual or other restrictions (other than official visa/ work. Permit

Approvals) or health conditions that may in any way. Prevent or restrict me form being

employed by you and fully performing my work and duties; and

3. I apply for employment with you by my own free will without any inducement or

representative from you or your agents.

4. Future that no Certificate of competency or license issued to me has ever been revoked

or suspended.

5. I also certify that my medical history contained above is true and any false statement or

undisclosed Material information about past illness or injury will disqualify me from

any employment benefits and claims.

Name: GAGANPREET SINGH

Date:

Contact this candidate