AG. MARITIME PRIVATE LIMITED Rev.**/**

***-*, **** ****** **, Andheri Kurla Road, Marol, Andheri East, Nov. 2014 Mumbai 400 059, Tel No.91-22-616***** AGM/001

RPS License No. RPSL-MUM-308

Employment Application Form

Rank Applied For: GP RATING Date ready to join 24/12/2016 Indos No 14GL2239 Surname Middle Name Fore Name

MISHRA RAJ RITU

Date of Birth Place of Birth Age (Yrs) Height(Cms) Weight (Kg,) Cover All Size Shoe Size 23/12/1994 VARANASI(UP) 22yr 159 64 32 07

Document Document No. Issue Date Expiry Date Issued At Passport M9010484 15/04/2015 14/04/2025 LUCKNOW

National Seamen Book CHN101857 28/10/2015 27/10/2015 CHENNAI Other Seamen Book

Other Seamen Book

Visa No. Issue Date Expiry Date Issued At Country Type of Visa US Visa C1/D _ _ _ _ _ -

Any other visa - - - - - -

Any other visa _ _ - _ - _

Nearest International Airport : SHIVAJI INTERNATIONAL AIRPORT MUMBAI (IND) Contact Details

Present Address : E602 Neelsidhi Splandour Permanent Address: S10/32 A5E M.A Road Hukulganj varanasi Sector 15 CBD Belapur Navi Mumbai.(India) Uttar pradesh.(India) Postal Code 400614 Postal Code 221002

Tel Mobile 893-***-**** Tel No. Mobile No. 945******* Email aczx1r@r.postjobfree.com aczx1r@r.postjobfree.com CIVIL STATUS: MARRIED / UNMARRIED

Next of Keen INDU MISHRA Family Details

Relation Ship MOTHER Relationship Surname Name Birth Date Address S10/32 A5E M.A Road Hukulganj Varanasi FATHER MISHRA SHIVA JI 01/01/1963 Uttar Paradesh.(India) MOTHER MISHRA INDU 12/06/1972 BROTHER MISHRA AMIT RAJ 17/01/1998

Tel No 945******* SISTER MISHRA PRIYANKA 13/07/1993 Email:

PRE-SEA TRAINING / APPRENTICE SHIP

NAME OF THE INSTITUTE / COLLEGE FROM TO TYPE OF DEGREE HIMT (Hindustan Institute of Maritime Training) 01-July-2014 31-Dec-2014 GP RATING Chennai.(India)

S.S.C. (10th) Marks 74% H.S.C. (12th) Marks % H.S.C. (PCM) Marks % Licences and Certification Information

STCW Certification STCW Reg Grade Number Issued Validity Issued at Certificate of Competency / Watchkeeping

Dangerous Cargo End Oil

Dangerous Cargo End Chemical

Flag State Endorsement / Other

GMDSS (GOC)

GOE

Flag State Endorsement GOC

Basic Training A-VI/1

Personal Survival Techniques A-VI/1-1 A PST C/B52/17 17/09/2014 DGS Fire Prevention & Fire-fighting A-VI/1-2 A FPFF C/B57/18 27/09/2014 DGS Elementary First-Aid A-VI/1-3 A EFA C/B54/18 24/09/2014 DGS Personal Safety & Social Responsibilities A-VI/1-4 A PSSR C/B52/18 20/09/2014 UNLIMITED DGS Proficiency in Survival craft & Rescue Boat A-VI/2 Advance Fire-Fighting A-VI/3

Medical First Aid ( All Officers) A-VI/4-1

Medical Care ( Master/Chief Officers) A-VI/4-2

SSO /Proficiency in Security Training For

Seafarers with Designated Security Duties

A-VI/6, Table A-

VI/6-2 of STCW

Convention as

amended in 2010

STCW 2010 Conversion Course for STCW 95

Courses

ROC Reg. 1/12, A-

I/12

ARPA

RANSCO

HAZMAT

OTFC A OTF C/B39/18 3/7/2014 DGS

CTFC

OIL TANKER

ADVANCE OIL TANKER

CHEMICAL TANKER

ADVANCE CHEMICAL TANKER

BRIDGE / ENGIINE ROOM RESOURCE

MANAGEMENT

BRIDGE TEAM MANAGEMENT

Ship Manoeuvring Simulator Course

ISM CODE

ISPS Fam

Oil Tanker/Chemical tanker familiarisation

LCH Simulator

Ship's captains medical care

Sea - Service

Vessel Manning Company Flag Type* GRT Engine type BHP Rank From To Duration

MM/DD

_ _ __ _ _ __ _ _ _ [1] _

[2]

LOG: Log Vessel, GC: General Cargo BC : Bulk Carrier WC: Wood Chip TKR : Oil Tanker GAS: Gas Tanker CC: Container Carrier

Has the applicant has ever signed off from a vessel on Medical Grounds. If yes, please furnish details. Yes No NO Name of Vessel Date signed off Reason / Brief Description of Illness / Injury / Accident Have you visited the doctor in the last 12 months for any surgery / Illness. If yes, please furnish details Yes No N0

Date of Illness / Surgery Details of Illness and Treatment received I apply employment with you by my own free will without any inducement or representative from you or your agents. I also certify that my medical history contained is true and any false statement or undisclosed material information about past illness or injury will disqualify me for any employment benefits and claims.

I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge and belief. I also affirm that 'no Certificate Of Competency or License issued to me has ever been revoked or suspended. Date: 16/12/2016 RITURAJ MISHRA

Place: Navi mumbai Signature of Seafarer

FOR OFFICE USE INITIAL CHECKED BY

Original licenses sighted

STCW and Training Certificates sighted

Experience confirmed by interview

Other details confirmed by interview

Reference Checked

Assessment & Evalution by Desination Date Signature

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