APPLICATION FORM
PASSPORT SIZE PHOTOGRAPH
Post applied for :2nd Engineer
Willing to accept lower rank? 2nd Engineer
Available From: 01/09/2015
1. Personal Details
First Name:Nimal
Middle Name :Kumara
Last Name / Surname :Wettasinghe
Nationality:Sri Lankan
Date of Birth :09-11-1953
Place of Birth :Colombo
Permanent Adress 63/1/c Kappetipola Road,Bandarawatta
Gampaha Sri Lanka
Present / Temporary Address
same Until
City Gampaha Pin
City Pin
Tel:009*-********* Mobile:
E mail:**************@*****.*** 0094-0714765544
Tel:
E mail:**************@*****.***
Nearest Airport : Colombo
Document
Country
No.
Issued
Place
Valid Until
Passport
Sri Lanka
N2529333
08/02/2010
Colombo
08/02/2020
Seamen’s Book
Liberian
Seamen’s Book
Marshall islands
Seamen’s Book
Panamanian
21CG600651
17/10/2013
Panama
16/10/2018
Seamen’s Book
Other:
Seamen’s Book
Sri Lanka
C 030876
21/12/1979
Colombo
09/04/2017
Seamen Registration No:
Indos No.
ECNR : Yes / No.
US visa – “C1” / “D” Yes/ No
Name of Nominee Mrs, T.D.C.De.Silva
In case of fatality :
Relation: Spouse
Address: No:63/1/C Kappetipola Road, Bandarawatta,Gampaha,Srilanka
TBCity Pin : Tel:0094-0717134981
Family Details
Relationship
First Name
Last Name
Date of Birth
Passport No.
Issued
Place
Valid Until
Wife
Chintha
De Silva
17/06/1963
Child F
Thilini
Dimitra
05/10/1992
Child M
Child M/F
Child M/F
Indicate the type of valid visa* USA CANADA BRAZIL UK OTHERS
Height ( In cms )173
Weight (In Kgs)65
Shoe Size :9
Boiler Suit Size : L
2. Certificates / Courses
A. Academic Qualification
School / College
Year of Passing
Highest Qualification attained
Class
BN College
1970
HSC
Grade 11
B. Training / Apprenticeship
From
To
Institution / University
Mechanical Fitter
09/01/1974
10/09/1974
Vocational Training center Colombo
C.Highest Competency Certificate Held
Issuing Authority :
Grade
Certification No.
Date Issued
Place Issued
Valid Until
National (Country)
Liberian
Panamanian
CH-Engineer
21CG600651
17/10/2013
Panama
16/09/2018
MarshallIsland
CaymanIsland
Hong Kong
Cyprus
D. Dangerous Cargo Certification
1. Endorsement on NATIONAL Certificate
Number
Date Issued
Place Issued
Valid Until
Petroleum
Liquefied Gas
Liquid Chemicals
E. Dangerous Cargo Endorsement ( Issued by Countries other than in Section 2D)
Country
Type @
Capacity #
Certificate No.
Date Issued
Valid Until 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 .g. AB/ Oiler)
Certificate No.
Date Issued
Place Issued
Valid Until
G. Courses Attended and Certificates Obtained
Course / Certificates
Certificate Number
Date Issued
Institution / Place Issued
Valid Until
Advanced fire fighting
06/12/2008
TS Rahaman Mumbai
Fire Prevention & Fire Fighting
SD-305/07-54/1000
02/11/2007
CINEC Colombo
Proficiency In Survival Craft [PSCRB]
12/12/2008
TS Rahaman Mumbai
Personal Survival Techniques
SD-300/07-47/0948
07/11/2007
CINEC Colombo
Medical First Aid
SD-313/08-09/0126
03/09/2008
CINEC Colombo
Ship Captain Medical (Medicare)
Personal Safety and & Social Responsibility
331/058/1802
03/04/1999
CINEC Colombo
Specialized Training Prog. (Petroleum)
SD-320/09-02/0043
15/05/2009
CINEC Colombo
Specialized Training Prog. (Chemical)
SD-320/09-02/0043
15/05/2009
CINEC Colombo
Specialized Training Prog. (Gas)
SD-320/09-02/0043
15/05/2003
CINEC Colombo
Oil Tanker Training Prog.
SD-321/09-09/0030
18/12/2009
CINEC Colombo
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
I.S.P.S
Proficiency in Fast Rescue Boat
3. General:
A. Have you ever been denied a foreign Visa? No.
If yes, state which Country and reason (Ifknown):
B. have you been the subject to court of enquiry or involved in a maritime accident? 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
Leo Shipping
Fair Deal Shipping
Name of Person to Contact
Mrs Tanuja Bandare
Mr Apostolos
Telephone
For Office Use Only
Company
Leo Shipping
India
Vessel
M/V Bei Hai
Type
Oil tanker
DWT/GRT
42263
Main Engine Type
Mitsubishi (UE)
BHP/TEU
10298
Rank
2nd Eng
Date from
03/01/2015
Date To
06/02/2015
Period
01 Demolition voyage
Chkd
Leo Shipping
India
M/V Aman Trader
BC
28164
B&W-6L60 MCE
12480
2ND Eng
23/03/2014
10/09/2014
06
Leo Shipping India
M/V Rio Gold
BC
23663
Sulzer RTA
10560
2nd Eng
19/10/2013
20/02/2014
04
Leo Shipping India
M/V Princess Lioness
BC
26195
B&W-6L60MCE
9680
2nd Eng
21/02/2013
06/09/2013
07
Leo Shipping- India
M/V Verginian
Container
16169
MAC
16320
2nd End
08/08/2012
01/08/2012
01 Dimolition voyage
Leo Shipping- India
M/V Maheshwari
BC
16816
Sulzer RND
10500
2nd Eng
15/07/2011
12/01/2012
06
Fair Deal-Greece
M/T Fair Dream
Oil Tanker
29600
B&W 6L67GFA
12000
2nd Eng
12/11/2010
14/03/2011
04
Fis Hanse-Germany
M/V Bulk Energy
BC
12365
Pielstic
13600
2nd Eng
13/03/2010
26/08/2010
05
GMC Kuwait
M/V Napolian
BC
18879
B&W GFA
12320
2nd Eng
18/05/2009
15/09/2009
04
Fair Deal-Greece
M/T Thea
Oil Tanker
68885
B&W 8K90GF
24800
2nd Eng
18/12/2007
04/08/2008
08
Fair Deal-Greece
M/T Thea
Oil Tanker
68885
B&W 8K90GF
24800
2nd Eng
06/03/2006
15/06/2007
15
Baaboud Shipping
Saudi Arabia
M/V Al Aboud
Ro-Ro
3500
B&W
3200
3rd Eng
13/06/2004
08/08/2005
14
Baaboud Shipping
Saudi Arabia
M/V Al Rasheedii
Ro-Ro
3500
MAN
3100
3rd Eng
18/02/2002
19/04/2003
14
Delmar Shipping Greece
M/V Med Spirit
Container
3100
Deutz
3400
3rd Eng
22/10/1999
22/06/2000
08
Collintas Marine Greece
M/V Vagelis
BC
29000
Sulzer RND
10500
3rd Eng
30/09/1997
10/12/1998
14
European Seaways Greece
M/V Ioanis
BC
17000
Sulzer RND
7500
3rd Eng
16/11/1995
31/10/1996
11
Prosperity Bay Shipping Greece
M/V Anna
BC
31600
Sulzer RND
11500
3rd Eng
19/07/1993
30/07/1994
12