Security Officer Medical Care
Resume:
This application form serves to provide with all information of the Applicant and will be treated as personal record should the applicant be employed.
Applicant is required to complete all parts in BLOCK CAPITALS. Copies of all certificates, seaman's book, passport and appraisal from the previous companies (if any) are to be attached.
POSITION APPLIED FOR
CHIEF COOK
DATE
25/5/2023
PERSONAL DETAILS
Surname
Middle Name
First Name
Nationality
ROY
GAUTAM
INDIAN
Date of Birth
Place of Birth
Religion
Age
12/03/1989
CAHKJIANDIGHI
HENDU
34 YEAR
Education Qualification
COC Grade
Marital Status
Height/Weight
10 PASS
COOK
MERRED
62 CM
Passport Number
Issuing Authority
Date of Issue
Date of Expiry
Coverall Size
U6260664
KOLKATA
03/03/2020
02/03/3030
M
Seaman’s Book Number
Issuing Authority
Date of Issue
Date of Expiry
Safety Shoe Size
MUM 42093
MUMBAI
09/10/2920
09/10/2030
7 NO
Mobile Phone Number
Home phone Number
Email Address ad20v6@r.postjobfree.com
Hometown Airport CCU KOLKATA
Permanent Address
VILLAGE -MALIGRAM PS-PINGLA DISTRICT-PASCHIM MEDINIPUR STET - WEST BENGAL PIN 721140
NEXT-OF-KIN
Name
Relationship
Contact Number
ARCHANA ROY
WIFE
707-***-**** I'm
Address (if different from the above)
Alternate Contact Person in case of Emergencies:
Full Style Address with Telephone Numbers
Officer Certification (STCW)
Certificate Number
Issuing Authority
Date of Issue
Date of Expiry
Certificate of Competency
General Operators’ Certificate
Flag State Licence - COC
CC/MUM/2020/E005128
MUMBAI PORT
06 November 2020
Lifetime
Flag State Licence - GOC
Rating Certification (STCW)
Certificate Number
Issuing Authority
Date of Issue
Date of Expiry
Watch keeping
Able Seafarer (STCW 2010)
STCW CERTIFICATES
Certificate Number
Issuing Authority
Date of Issue
Date of Expiry
FP & FF
SEACOM MARITIME COLLEGE
28/02/2020
UNLIMITED
AFF
PST
SEACOM MARITIME COLLEGE
28/02/2020
UNLIMITED
PSCRB
EFA
SEACOM MARITIME COLLEGE
28/02/2020
UNLIMITED
MFA
Medical Care
PSSR
SEACOM MARITIME COLLEGE
28/03/2020
UNLIMITED
STSDS
3010036621200109
SEACOM MARITIME COLLEGE
03/03/3020
UNLIMITED
Refresher
OCTFC
Copdgsoac23102656
Dg siping
26/5/2023
Unlimited
RADAR
BTM/BRM
ERM
Ship Handling
ECDIS
High Voltage Safety & Switch Gear
ISM Code
Fast Rescue Craft
Ship’s Cook
Food Handling
MLC
Ship Security Officer
Any Other Certificate
OFFSHORE CERTIFICATE
Certificate Number
Issuing Institute
Date of Issue
Date of Expiry
BOSIET (OPITO Approved)
HUET / EBS
Rigging & Slinging
H2S Awareness
MARLIN
Banksman
Crane Operator
DPM
Dynamic Positioning (Unlimited)
Dynamic Positioning (Limited)
Dynamic Positioning (Advanced)
Dynamic Positioning (Basic)
DP log book
Any Other Certificate
Type of Offshore Medical
Certificate Number
Medical centre
Date of Issue
Date of Expiry
APPENDIX -IV
BH 1191
SHAH NURSING HOME DR. SUNIL SHAH
09/12/2021
08/12/2023
Coved 19 Vaccine Details
Vaccine Name
Date of vaccine
Dose 1
COVIDSHILD
6 JULAI 2021
Dose 2
COVIDSHILD
8 OCTOBER 2021
Dose 3
COVIDSHILD
3 AUGUST 2022
Record of Sea Service
Company
Name of Vessel
Type
Rank
GRT/BHP
Main Engine & Propulsion
From
To
No. of days On-board
Charterer
MV SPARLYRA
OCS INDIAN PVT Ltd
Supply vessel
Cook
1565
03/09/2010
11/04/2010
MV DOMINGUE
OCS INDIAN PVT Ltd
Supply vessel
Cook
1678
6/7/2011
20/6/2012
MV SPARLYRA
OCS INDIAN PVT Ltd
Supply vessel
Cook
1678
5/11/2012
18/10/2013
NKD
NOBLE DELING PVT Ltd
JACK UP RIG
COOK
15164
2/12/2013
4/6/2014
NKD
NOBLE dealing
Jack UP RIG
Cook
15164
4/8/2014
5/2/2015
BG panna
OCS INDIAN PVT LTD
Oil platform
Cook
15566
7/2/2015
9/8/15
Shell panna
OCS INDIAN PVT LTD
Oil platform
Cook
15566
11/10/2015
12/5/16
Shell panna
OCS INDIAN PVT LTD
Oil platform
Cook
15566
10/7/2016
11/12/2016
Shell panna
OCS INDIAN PVT LTD
Oil platform
Cook
15566
13/2/2017
15/8/17
Shell panna
OCS INDIAN PVT LTD
Oil platform
Cook
15566
13/3/2018
15/9/18
Shell panna
OCS INDIAN PVT LTD
Oil platform
Cook
15566
13/3/2019
12/9/2019
Shell panna
OCS INDIAN PVT LTD
Oil platform
Cook
15566
10/11/2019
10/5/2020
Ocean Promise
Ocean sparkle Indian Pvt Ltd
Tug vessel
Cook
493/147
17/3/2021
12/10/2021
Ocean Promise
Ocean sparkle Indian Pvt Ltd
Tug vessel
Cook
493/147
13/12/2021
1/7/2022
TAURUS 24
Keeling Maritime Pvt Ltd
Diving supply vessel
Cook
1880
29/9/22
2/4/2023
JSW Raigad
Nautilus shipping indea Pvt Ltd
Jenarail Cargo
Chief cook
5550
19/5/2023
14/12/2023
APPLICANT’S DECLARATION
Medical History / Background
Yes/No
If yes, please provide details
Do you have history of illness such as tuberculosis, high blood pressure, mental illness etc…?
No
Do you have physical disability?
No
Have you ever been hospitalised, operated or currently undergoing any medical treatment?
No
Have you had premature termination of employment agreement?
No
Have you been dismissed or logged for misconduct?
No
Have you been refused entry by any country?
No
Have you ever been charged in court for any offence?
No
Do you have alcohol drinking habit?
No
REFERENCE
Name
Name
Company
Company
Position
Position
Contact
Contact
I confirm that the information given by me herein is true and correct. I also understand that any falsification or misrepresentation in my personnel records can result in my immediate dismissal and maybe subject to legal action if I am employed by the Company. I do agree to submit myself to a thorough medical examination, which I must successfully pass as one of the conditions for being accepted for employment.
Date: 25/5/2023
Applicant’s Signature: Gautam Roy
Contact this candidate