POST APPLIED:- */E

OFFICERS APPLICATION FORM

Personal Details:

First Name: SATISH

Middle Name: RAMCHANDRA

Surname: BELOSE

Nationality: INDIAN

Date / Place of Birth: 02/10/1960

Available From: IMMEDIATELY

Post Applied For 3rd/ENGINEER

Willing to Accept Lower Rank?

Last drawn wages:

MUI Membership No.: -- 034526

INDOS No.: 01EL2005

Expected Wages: AT PAR

Permanent Address: SIDDESHWARNAGAR

Present Address: : SIDDESHWARNAGAR

FLAT No 19,Bldg A-2, TINGRENAGAR RD,

FLAT No 19,Bldg A-2, TINGRENAGAR RD,

VISHRANTWADI,PUNE

VISHRANTWADI,PUNE

PIN Code:411015

PIN Code:411015

STD Code: 020 Phone Number:

STD Code: 020 Phone Number:

Email:adbb2o@r.postjobfree.com

Mobile No:705-***-****/996*******

Travel Documents Details:

Passport No:

Date of Issue

Place of Issue

Date of Expiry

ECNR

Minimum 4

Blank Pages

L9658446

26/05/2014

Pune

25/05/2024

NA

YES

U.S. VISA

C1/D No.:

Seaman’s Book (CDC)

Number

Date of Issue

Place of Issue

Expiry Date

Indian

BY 58640

19/01/2016

MUMBAI

18/01/2026

Panamanian

BELIZ

Certificate of Competency Details:

License

Grade

Number

Date of Issue

Place of Issue

Date of Expiry

Indian

MEO CLIV

95Z-0472

03/10/2006

MUMBAI

23/08/2024

U.K.

Panamanian

BELIZ

GMDSS (Deck Officers)

GMDSS Endorsement

Yellow Fever Details

Number

Date of Issue

Place of Issue

Expiry Date

10767 09/09/2010

MUMBAI

08/09/2020

Full Name of Kin : Mrs ANJANA BELOSE

Relationship: WIFE

Address of Next of Kin:

SIDDESHWARNAGAR

FLAT No 19,Bldg A-2, TINGRENAGAR RD,

VISHRANTWADI,PUNE PIN CODE 411015

STD Code: 020 Phone Number:

Mobile- 705-***-****/996*******

Next of Kin Details:

Family Details

Name

D.O.B.

PPT. No.

D.O.I.

Place of Issue

D.O.E.

ECNR

Wife

ANJANA BELOSE

07/07/1971

G7246292

14/02/2008

PUNE

13/02/2018

Child M/F

Child M/F

Height : 180 Cm:

Weight: 74 Kg:

Boiler Suit Size ( S, M, L, XL, XXL ) : XL

Shoe Size ( 6, 7, 8, 9, 10, 11 ) :9

Details of courses & certificates:

STCW Courses:

Number

Date of Issue

Date of Expiry

Issued By / Place of Issue

Advanced Fire Fighting (AFF) / FIRE PREVENTION & FIRE FIGHTING (FPFF)

AIIMT/MUM/REF/AFF/B143/2403

27/12/2016

26/12/2021

AIIMT

Medical First Aid (MFA) / ELEMENTARY FIRST AID (EFA)

AIIMT/MUM/MFA/B46/984

28/12/2016

27/12/2021

AIIMT

Proficiency in Survival Craft & Rescue Boat (PSCRB)

BPMA/PSCRB-RF/11913/2016

26/12/2016

25/12/2021

AIIMT

Personal Survival Technique (PST)

34975

18/02/1991

T S RAHAMAN

Personal Survival & Social Responsibility (PSSR)

203**********

27/04/2019

OERC ACADEMY

Medicare ( Deck Officers )

Radar Observer / ARPA ( Deck Officers )

Radar Simulator (RANSCO)

Ship Handling Simulator

SSO Course

14427

05/02/2014

IMMARBE

Fast Rescue Boat (FRB)

ECDIS ( Deck Officers )

Revalidation / Upgradation Course

203***********

20/05/2019

22/05/2019

OERC MUMBAI

Engine Room Simulator

Tanker Courses:

LCHS

Oil Tanker Familiarization (OTFC)

Chemical Tanker Familiarization (CTFC)

Gas Familiarization (GTFC)

Petroleum Tanker Safety (TASCO)

PMTRI/TASCO/03/001/2013

16/03/2013

15/02/2018

PENTAGON

Chemical Tanker Safety (CHEMCO)

PMTRI/CHEMCO/05/001/2013

25/05/2013

24/05/2018

PENTAGON

Gas Tanker Safety (GASCO)

Optional Courses:

Hazmat Course

Bridge Team Management (BTM)

Others: STSDSD

131***********

15/10/2013

SCI MTI

Dangerous Cargo Endorsements (DCE)

Nationality

Grade/ Level I/II

Number

D.O.I

Place of Issue

D.O.E

Oil

INDIAN

I

M/O/1/E/13/22667

12/02/2013

MUMBAI

Chemical

INDIAN

I

M/C/1/E/13/2324

28/05/2013

MUMBAI

Liquefied Gas

DP Certification (Please tick accordingly)

Type of Certificate

Basic

Advance

Limited

Full

Length of DP Watch keeping

3 MONTH (Total DP hours & months onboard)

Vessel Class

DPI

Offshore Certificates

Certificates

Number

Date of Issue

Date of Expiry

HUET

Police Clearance Certificate ( PCC )

BOSEIT (OPITO Approved)

Please tick if YES

Food Handling

Crane Operator Training Certificate

Rigging and Slinging

Answer Yes or No to the following questions. If Yes, give details below

Yes

No

1

Has any previous employer dismissed you for misconduct?

NO

2

Have you had any serious illness, injury or operation affection your work

NO

3

Do you have any physical handicap including eyesight or hearing

NO

4

Have you ever being convicted in a court of law in any country

NO

5

Can you swim

YES

Declaration of Applicant

Total Sea Service of Position Applied for:

Type: AHT/Tug/Barge/Utility boat/Others

Years:

Months: 3 &

Tanker

Years: 3

Months: 8

Bank Account Details :

Account Holder’s Name : SATISH RAMCHANDRA BELOSE

Name Of Bank & Account No. : S.B.I

Branch & Address : SPBP

DECCAN GYMKHANA. J.M ROAD

A/C No : 103******** (IFSC SBIN00043)

PUNE. M.S

Previous Sea Service (Commencing from Last Vessel) (PLEASE FILL THE GRT/KW AS PER STCW REQUIREMENT) (1KW = 1.37 BHP)

Sr.No.

Name of Company

Name of Vessel

Type

BHP

GRT

Rank

From

To

Total DAYS

Reason for S/OFF

1

SEVEN ICELAND

M.T.ORCHID

P/T

11600

29000

Technecian2/E

05/06/16

13/09/16

100

CONTRACT

2

SEVEN ICELAND

M.T VICTORY

M/R

9060

46000

Technecian 2/E

27/04/15

24/09/15

151

CONTRACT

3

ADMIRAL MARINE

SCI PANNA

DPII

2400X2 KW

2/E

10/11/14

19/02/15

103

CTONTRAC

4

INTIGRETY SHIP MGM

M.V ANA

B/C

8379 KW

21000

2/E

28/03/14

19/05/15

53

DELIVERY

5

ACCORD SHIP MGM

M.V NAVADHENUPURNA

B/C

18489

48459

3/E

11/11/11

13/03/12

123

CONTRACT

6

SOVEREIGN SHIP MGM

M.V UNION SPIRIT

B/C

11550

27000

3/E

26/09/10

22/01/11

118

CONTRACT

7

STAR SHIP MGM

M.V PEARL OF SHARJHA

B/C

13500

85000

3/E

05/07/07

28/01/08

207

CONTRACT

8

NAUTICAL MARINE

M.T ZIRKU

VLCC

15400

105217

3/E

08/02/07

18/05/07

100

CONTRACT

9

NAUTICAL MARINE

M.T SHAYBHA

P/T

11640

11640

3/E

12/11/05

07/07/06

237

CONTRACT

10

NAUTICAL MARINE

M.T VOYEGER

P/T

12300

47000

3/E

20/07/05

20/11/05

123

CONTRACT

11

NAUTICAL MARINE

M.T BERBER

P/T

11400

43000

3/E

11/04/03

10/08/03

129

CONTRACT

12

OBM

M.V DELMAS PROTIA

B/C

11254

27600

3/E

13/05/02

16/12/02

207

CONTRACT

13

USM

M.V FINCH ARROW

B/C

11200

46400

3/E

11/11/01

30/01/02

82

CONTRACT

14

USM

M.V.HALEEM

G/C

3/E

155

CONTRACT

15

USM

M.V RIZCONENTERPRI SE

B/C

3/E

180

CONTRACT

16

USM

M.V AZIZ

B/C

3/E

322

CONTRACT

17

9060

46000

3/E

27/04/15

24/09/15

151

CONTRACT

Pre Sea Training / Apprentice (Ship)

Name of Institute / College

From

To

Type of Degree

MDL MUMBAI

MAR 1980

FEB 1984

4 YEARS MARINE ENGINEERING TRAINING

Educational Background

Qualification

School / College

From

To

Percentage / Grade

BSc

ELPHINSTONE

1975

1980

PASS

Technical Background

Degree / Diploma

Institute / College

From

To

Percentage / Grade

Medical History

(a)Have you ever signed off from a ship due to Medical reasons, (If Yes, give details)

/NO

Name of Vessels

Date of Occurrence

Brief Description of Illness / Injury/ Accident

(b) Did you suffer or Are you Presently suffering from any Disease which keeps you unfit

for sea service.

/NO

(c) Are you addicted to alcohol or drugs of any kind.

/NO

(d) Have you suffered from following

Malaria Diabetes Epilepsy Nervous Disability

NO NO NO NO

(e) Did you ever undergo psychiatric treatment : /NO

Reference

Sr. No.

Name of the company

PIC

Designation

Phone No

1

Girish Kotwal

C/E (M.D)

2

C/E (Director)

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; further, that no Certificate of competency or License issued to me has ever been Revoked or Suspended.

SATISH BELOSE 18/01/2019

Applicant’s Signature Date

For Office use :-

Received By:

Remarks: Date

Contact this candidate