APPLICATION FORM
.
Position
Position applied for:
MASTER
Are you willing to accept any other positions?
NO
If YES, which positions would you consider?
-
Readiness From
** ** *** 2019.
2
Personal details
Last Name:
BHUIYAN
First Name:
MD. MUNIRUL
Middle Name:
ISLAM
Date of birth
20 DEC 1961
Place of birth
NOAKHALI
Nationality
BANGLADESHI
Height
165 CM
Weight
81 KG
ID Mark
Blood Group
“O +VE
Chest
101 cm
Waist
109 cm
Boiler Suite
XL
Safety Shoe
43
Cap
National ID 2696
WhatsApp ;
YES
Company ID
Address:
15200 FORESIGHT DRIVE, CARY, NC 27519, USA
Post code:
27519
Hand Phone No.
Telephone No.
E-Mail ID:
ada5x1@r.postjobfree.com
3
Education Background
Name
From Year
To Year
Highest Qualification Attained
School
KHILPARA HIGH SCHOOL, NOAKHALI
1965
1977
S.S.C.
College
TITUMIR COLLEGE, DHAKA
1978
1980
H.S.C.
Pre Sea Training
MARINE FISHERIES ACADEMY, CTG
1981
1983
B.Sc. NAUTICAL STUDIES
Other Qualifications
FLEETWOOD NAUTICAL COLLEGE, UK
1999
2000
HND in Nautical Science
4
Identity documents
DOCUMENT
COUNTRY
NUMBER
ISSUE DATE
PLACE
EXPIRY DATE
Passport:
Bangladesh
BF0702717
18 MAY 2015
DHAKA, BANGLADESH
17 MAY 2020
Seaman’s book:
National
C/O/1141
29 OCT 2007
CTG, BANGLADESH
28 OCT 2022
Bahamian
Seaman ID Card
YES /
050001006
03 JAN 2011
DHAKA, BANGLADESH
13 June 2026
Visa – US ‘C1/D’
YES
US EMBASSY, DHAKA
24 JULY 2024
Other Visa
YES/NO
US Green card holder
24 JULY 2024
Yellow Fever Vaccination
YES
2020
Holding Australian MCV
YES /
10 AUG 2015
09 AUG 2018
5
Family details
Next Of Kin/Nominee
Marital Status :
MARRIED
Relationship :
WIFE
Last Name:
MAHENUR
First Name
UMMUL ARA
Address:
15200,Foresight Drive, Cary, NC 27519, USA
Post code:
27519
Hand Phone No.
Telephone No.
Relation
.Name: UmmuaraaraaraAarMMMahenur
P.O.B.
PPT NO.
D.O.I.
P.O.I.
D.O.E.
Wife
Ummul Ara Mahenur
Dhaka.
BK0119189
03-02-2016
Dhaka
02-02-2021.
Note: Second Next Of Kin / Nominee (In case of voyage with family)
Relation
Father in-law
Name
Mr. Ruhul Amin
Address:
6.MayaKanon, Bashabo, Dhaka-1214, Bangladesh
Mother’s Name
Hand Phone No.
880-1715469581
Telephone No.
6
National Certificate of Competency (Highest certificate of competency held)
Class/Grade
Issuing Country
Certificate No.
Date Issued
Place Issued
Valid Until
MASTER (II/2)
UNITED KINGDOM
CoC0028271
25 OCT 2002
MCA, UK
10 JUL 2022
GMDSS
UNITED KINGDOM
GG 03747
11 OCT 1993
MCA, UK
10 JUL 2022
6a
National Dangerous Cargo Endorsements
Endorsement Type
Certificate No.
Date Issued
Place Issued
Valid Until
Petroleum
Liquefied Gas
Chemicals
7
Flag State Equivalent Certificates Of Competency issued by other countries (Issued by countries other than in Section 6)
Class
Issuing Country
Certificate No.
Date Issued
Place Issued
Valid Until
MASTER
SINGAPORE
COE-D0155475
03 MAY 2018
SINGAPORE
10 JULY 2022
GMDSS
SINGAPORE
COE-R0133322
03 MAY 2018
SINGAPORE
10 JULY 2022
MASTER
MARSHALL ISLANDS
589271
23 AUG 2018
MUMBAI
10 JULY 2022
GMDSS
MARSHALL ISLANDS
GG03747
23 AUG 2018
MUMBAI
10 JULY 2022
7a
Flag State Equivalent Dangerous Cargo Endorsements (Issued by countries other than in Section 6a)
Country
Endorse Type/ Level
Certificate No.
Date Issued
Place Issued
Valid Until
Liberia
Marshall Islands
Panama
8
Certificates ( STCW and Value added)
Course
Institution
Place
Issue Date
Cert. No.
Expiry Date
Personal Survival Techniques
MIST, DHAKA
BANGLADESH
25-09-2016
039014084
14.06.2021
Basic / Advance Fire Fighting
RESOLVE, FL
USA
12.05.2017
27286
11.05.2022
Elementary / Medical First Aid
IMTA,DHAKA
BANGLADESH
25-09-2016
041 01 4081
15-07-2021
Capt’s Medical Guide/ Medical Care
IMTA, DHAKA
BANGLADESH
27.03.2019
RT-MEDI/1904/01
26-03-2024
Proficiency In Survival Craft & RB
BLUE WATER
USA
12.05.2017
90081/05
11.05.2022
Human Relations – PSSR
B&FCOLLEGE
UK
15.02.1999
1999
N.E.D.
Automatic Radar Plotting Aid (ARPA)
B&FCOLLEGE
UK
29.11.1999
094
N.E.D.
Electronic Navigation System
LOWESTOFT
UK
13-031992
249
Navigation Control
Ship Security Officer
IMTA,DHAKA
BANGLADESH
28.03.2019
048093035
27.03.2024
Tanker Familiarization (Oil,Chem,Gas)
Advance Oil Tanker Safety
Advance Chemical Tanker Safety
Advance Gas Tanker Safety
Liq. Cargo Handling Simulator
Bridge Resource Management
Bridge Team Management
IIMT, DHAKA
BANGLADESH
15.11.2003
BTM/0306/01
Marine Environment Protection
Ship Maneuvering /Handling Simulator
Hazardous Materials
Ship Board Safety Officers
Elect. Chart Display & Info System
UMA,DHAKA
BANGLADESH
21.05.2015
UMA/ECDIS/MCA/1415
20.05.2020
9
9
Record of previous service
(Please give a full record starting with the last vessel on which you served)
VESSEL NAME
COMPANY#
VESSEL TYPE
FLAG
G.R.T.
D.W.T.
TEU’S
YEAR BUILT
RANK
SIGN ON DATE
SIGN OFF DATE
DURATION
YY-MM-DD
REASON FOR SIGN OFF
OCEAN GRACE
MERCANTILE SHIPPING LINES,
BULK
MARSHALL ISLANDS
31242
56029
2005
MASTER
02-07-2018
12-03-2019
00-08-10
END OF CONTRACT
MP ULTRAMAX - 1
MSI SHIP MANAGEMENT
BULK
SINGAPORE
36286
64000
2016
MASTER
04-05-2018
21-06-2018
00-01-17
CREW MANAGEMENT CHANGED
M.V.GREAT ROYAL
VANGUARD MARITIME LTD
BULK
BANGLADESH
23263
42174
1994
MASTER
20.09.2016
06-03-2017
00-05-17
END OF CONTRACT
M.V.SPARNA
SANTOKUSENPAKU
BULK
PANAMA
31385
54881
2008
MASTER
21.10.2015
01.05.2016
00-06-09
END OF CONTRACT
M.V.SPARNA
SANTOKUSENPAKU
BULK
PANAMA
31385
54881
2008
MASTER
05.10.2014
09.05.2015
00-07-04
END OF CONTRACT
M.V.SPARNA
SANTOKUSENPAKU
BULK
PANAMA
31385
54881
2008
MASTER
07.05.2013
09.01.2014
00-08-02
END OF CONTRACT
GLOBAL TRINITY
SANTOKUSENPAKU
LOG/BULK
PANAMA
17019
28202
---
2011
MASTER
29.07.2012
22.12.2012
00-04-24
END OF CONTRACT
JAHAN MONI
BRAVE ROYAL SHIP MGT
BULK
BANGLADESH
25600
44377
---
1996
MASTER
26.11.2011
01.05.2012
00-05-06
END OF CONTRACT
KHADIZA JAHAN
BRAVE ROYAL SHIP MGT
BULK
BANGLADESH
22271
37596
---
1985
MASTER
02.02.2011
19.07.2011
00-05-18
END OF CONTRACT
SHAHRIAR JAHAN
BRAVE ROYAL SHIP MGT
BULK
BANGLADESH
22053
37568
---
1985
MASTER
24.12.2009
06.09.2010
00-08-14
END OF CONTRACT
SHAHRIAR JAHAN
BRAVE ROYAL SHIP MGT
BULK
BANGLADESH
22053
37568
---
1985
C OFF
05.09.2009
24.12.2009
00-03-20
PROMOTION
BRAVE ROYAL
BRAVE ROYAL SHIP MGT
BULK
BANGLADESH
20277
34607
---
1984
C OFF
27.04.2009
26.08.2009
00-04-05
END OFCONTRACT
DARYA SHANTHI
ANGLO EASTERN- HK
BULK
HONG KONG
38392
73389
---
2001
C OFF
02.06.2008
14.11.2008
00-05-13
END OF CONTRACT
GREAT AMBITION
SINOTRANSSHPG- HK
BULK
HONG KONG
38426
73725
---
1999
C OFF
14.02.2007
15.10.2007
00-08-02
END OF CONTRACT
GREAT GAIN
SINOTRANSSHPG- HK
BULK
HONG KONG
16651
27140
---
1998
C OFF
12.10.2005
04.06.2006
00-07-23
END OF CONTRACT
EASTERN SEA
AL UNITED MTM - BD
MP/CONT
MALTA
10018
12665
---
1983
C OFF
26.03.2004
06.02.2005
00-10-11
END OF CONTRACT
AL MUZTABA
CONTINENTAL L.A.
G.C.
BANGLADESH
4674
7000
C OFF
04.03.2003
30.08.2003
00-05-27
END OF CONTRACT
A A VENTURE
CONTINENTAL L.A.
MP/ CONT
BANGLADESH
6393
10000
C OFF
24.09.2001
29.07.2002
00-10-06
END OF CONTRACT
AL MUZTABA
CONTINENTAL L.A.
G.C.
BANGLADESH
4674
7000
C OFF
10.05.2000
17.06.2001
01-01-07
END OF CONTRACT
FARENCO
WAH TUNG SHIP MGT
BULK
HONG KONG
79694
172536
2 OFF
12.10.1997
29.08.1998
00-10-18
END OF CONTRACT
NAVALIS
WAH TUNG SHIP MGT
BULK
HONG KONG
74672
13361
2 OFF
21.04.1997
11.10.1997
00-05-21
END OF CONTRACT
PEONIA
WAH TUNG SHIP MGT
BULK
HONG KONG
15274
15274
3 OFF
16.11.1995
28.10.1996
00-11-13
END OF CONTRACT
MV CONTINENT -1
CONTINENTAL LA.
CARGO/REFFER
BANGLADESH
5000
7000
2 OFF
01.01.1994
24.11.1994
00-11-13
END OF CONTRACT
SS BRITANIS
CHADRIS CRUISE LINES
CRUISE
PANAMA
15412
4264
3 OFF
16.01.1988
09.03.1990
02-1-23
END OF CONTRACT
SS BRITANIS
CHADRIS CRUISE LINES
CRUISE
PANAMA
15412
4264
D/CADET
06.11.1985
27.10.1987
01-11-21
END OF CONTRACT
10
Type of Cargoes / Parcels carried (For tanker please mention number of segregated parcels / experience on COW/IG)
Bulk cargoes/ Grain/ Ores/ Bulk Cement/Bulk sugar/Canola/Steel coil/Slab,/ Container/ Project cargo/ Timber etc.
10a
Details of Inspections Experience (Oil Major, USCG, AMSA etc.)
USCG & AMSA Many times.
10b
Other Experience (Trading route, Crane, Pump, Grabs, Dry dock, Takeover etc. )
Trans pacific/ Trans Atlantic/ South east Asia/ South America./ Yes onboard (crane/grabs), Six/ seven times dry docking attended as Chief office & Master. Yes have taken over experience.
11
Sailing Experience: (Please advise PRESENT RANK EXPERIENCE on each type of vessel)
CONT/RFG (MM-DD)
G. CARGO (MM-DD)
BC/OBO/RR (MM-DD)
PCC/PCTC (MM-DD)
OIL/VLCC (MM-DD)
CHEMICAL (MM-DD)
PRODUCT (MM-DD)
LPG/LNG (MM-DD)
OTHERS (MM-DD)
TOTAL RANK EXPERIENCE
56 M
56 M
LAST SALARY DRAWN
EXPECTED SALARY
12
References (Please give the name and address of your current or immediate past employer)
Name of Company
MERCANTILE SHIPPING LINES LTD.
Name of person to contact
CAPT. MATIUL ISLAM, DPA.
SUPER &DPA.
Address
WORLD TRADE CENTER (5TH FL) 5((GROUNFLOOR).
102-103, AGRABAD, C/A .CHITTAGONG. – 4100, BANGLADESH
No. / Facsimile
880-1701210491(CELL), 880-312519730-32 (OFFICE)
880-********* (OFFICE)
E-Mail / Website
ada5x1@r.postjobfree.com
13
Miscellaneous (Please give the details of your FC account)
Name of Bank
Branch
Account Name
Address
Account No.
Swift / BIC Code
14
Medical history
Have you ever signed off a ship due to medical reasons?
Yes/No
NO
Have you undergone any operation in the past?
Yes/No
NO
Have you consulted a doctor during the last 12 months for an illness/accident?
Yes/No
NO
Do you have any health or disability problems now?
Yes/No
NO
(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)
15
Declaration
I hereby declare that the above particulars are true and authorise you to contact the referees listed above.
MD. MUNIRUL ISLAM BHUIYAN
25th Dec’2019
Name/Signature
Date