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Relationship:

ApplicationForm/PersonnelDataUpdateForm

(A)PERSONALPARTICULARS(ASINPASSPORT)

Next of kin: SMT. GEETA VERMA Relationship: MOTHER DOB: Alternate next of kin:

(incase of family joining)

Address:

MOB.

Family Data Post applied for: DECK CADET Willing to accept lower rank? Yes No Available from: 19/02/2021 First Name: RISHABH Middle Name: Last Name/Surname: VERMA Nationality: INDIAN Date of Birth: 20-11-1995 Place of Birth: PATHANKOT Height

(InCMS) 170

Weight(InKGS) 65 Smoker/Nonsmoker YellowFever UnionMembersh BloodGroup B+ Veg./Non-Veg. DOI DOE ip

BATCH/LOTNo.

YES NO

BoilerSuitSize: MED/LARGE/XL/XXL ShoeSize: 6 10/09/2018 LIFETIME BATCH NO 571 PermanentAddress: RISHABH VERMA, SHREE RAM VIHAR LocalAddress: OPPOSITE TUSHAR MARBLE HOUSE, MANWAL CHOWK

City: PATHANKOT Tel.: City: Tel.:

Postal Code: 145001 Mobile: +91-855******* PostCode: Mobile: E-mail: adlia1@r.postjobfree.com

Documents No. Date of Issue

DD/MM/YYYY

Place of Issue Date of Expiry

DD/MM/YYYY

Passport:Country - INDIA S8237174 22/11/2018 JALANDHAR 21/11/2028 Seaman’sBook(CDC):National MUM 269834 13/01/2017 MUMBAI 12/01/2027 Seaman’sBook(CDC):Norwegian

Seaman’sBook(CDC):Liberian

Seaman’sBook(CDC):Panamanian

Seaman’sBook(CDC):MarshallIsland

Other(CDC):

ValidUSVisa“C1/D” YES/NO DateofExpiry: PassportECNR:Yes/No AustralianMaritimeCrewVisa Yes/No DateofExpiry:

Relationship FirstName LastName DOB PassportNo. PlaceIssued Validuntil Spouse

ChildM/F

ChildM/F

*Indicate Type of Valid Visa: USA CANADA BRAZIL UK OTHERS Anniversary Date:

*Please check if visa is valid for the tenure onboard. Applicant’s Signature

FORMNO : EMSPL/02/2013

REV.NO : 01/2013

[2 ! /10]

(B)Education/OtherQualifications:

EDUCATIONAL QUALIFICATION

PRE-SEATRAINING/APPRENTICESHIP/MARINEENGINEERING/NAUTICALDEGREEORDIPLOMA CERTIFICATES OF COMPETENCY:

LISTOFS.T.C.W./OTHERCOURSESDONE

DangerousCargoCertification:

Applicant’s Signature

CLASS AFFILIATION

Year of Passing ResultGrade(1st,2nd,

3rdor A,B,Cetc)

10+2 (NON MED) PSEB 2014 B

Pre-Sea Training Training Institution /Company Name From-To ResultGrade(1st, 2nd,

3rdor A,B,Cetc)

DNS INTERNATIONAL MARITIME INST., GREATER NOIDA 09-02-16 to 08-02-17 PASS Highest Competency Certificate Held

Date of Passing Examination

Issuing Authority Grade Certificate

No.

DOI Place

Issued

Valid until

National (Country)

Liberian

Panamanian

Marshall Island

Norwegian

Hongkong

Others

GMDSS

GMDSS (Endorsement)

Courses Cert. No. Date of Issue Place of Issue

1) FPFF /Advanced Fire Fighting FPFF-602*-**-**-**** IMI, GREATER NOIDA 2) Proficiency in Survival Craft &RB /PST PST- 467*-**-**-**** IMI, GREATER NOIDA 3) Elementary/Medical First Aid/Medicare EFA-499*-**-**-**** IMI, GREATER NOIDA 4) PSSR PSSR-501*-**-**-**** IMI, GREATER NOIDA

5) CTFC/CHEMCO

6) OTFC/TASCO

7) GTFC/GASCO

8) LCHS : (Management /Operational)

9) Ship Manouvering Simulator Course

10) Radar Observer Course /ARPA

11) Radar Simulator Course /RANSCO

12) BTM/BRM

13) ISPS (SSO) Course

14) NIS Familiarisation Course

15) C.O.C. Revalidation Course

16) INDOS NO (Mandatory Requirement) 16NL0208 - -

17) Others (Specify)

18)SECURITY TRANING FOR SEAFARERS ST-126*-**-**-**** IMI, GREATER NOIDA 19) OCTCO BTOCTCO/361/073/018-**-**-**** SIMS, NEW DELHI 1.EndorsementonNATIONALCertificate Level Number DOI PlaceIssued ValidUntil Petroleum

Liquified Gas

Liquid Chemicals

2.Other Endorsements

[3 ! /10]

(C)SEASERVICE:(StartFromLastVesselServed)

Applicant’s Signature

Name of

the

Company

Name of the

Vessel

Flag of

Vessel

Typeof

Vessel

DWT(D)

GRT(G) Rank

From

dd/mm/yy

To

dd/mm/yy

Total

M/D

ALMIGHTY

MARITIME

M V BULK

ECUADOR

LIBERIA BULK (D)57937

(G)32309

DECK

CADET

07/02/2020 04/11/2020 8 MONTHS

27 DAYS

[4 ! /10]

(D) ExperienceMatrixofEngineerOfficer

Pleasemark‘Y’againstyourrankinthecell,ifthatexperienceisapplicabletoyou S.No

.

Crane Make C/E 2/E 3/E 4/E E/O Any Breakdown experience /Remarks Experience on Deck /Cargo Machinery

1 Haaglund

2 Liebherr

3 IHI

4 Mitsubishi

5 NMF

6 Atlas

7 BLM

8 MacGregor

9 Any Other

Grab Make

1 SMAGPeiner

2 ORTS

Experience on Reefer Machinery /Reefer Container

1 Direct System

2 Indirect System

3 Carrier Transicold

4 Thermoking

5 Daikin

6 Mistubishi

7 Any Other

Experience on Oil /Chemical /Gas Tankers

1 Framo Pumps

2 Centrilina Pumps

3 Steam Turbines

4 Any Other

Experience on Propulsion System /Manoeuvering System 1 CPP

2 Bow/Stern thruster

3 TwinScrew

4 NOR Control

5 Kongsberg

6 Any Other

Experience onAuxilliary Engines

1 Yanmar

2 Daihatsu

3 Sulzer

4 MAN B&W

5 Cummins

6 Caterpillar

7 Pielstik

8 Volvo Penta

9 Any Other

[5 ! /10]

Applicant’s Signature

S.No

.

Crane Make C/E 2/E 3/E 4/E E/O Any Breakdown experience /Remarks Experience of major overhaul /breakdown

1 Drydock

2 M/E Turbocharger

3 M/E Governer

4 M/E Cyl. Liner

5 Thrust Block

6 A/E Crankshaft

7 Alternator overhaul

8 Steering Gear

9 Any Other

Experience in Disaster Management

1 Grounding

2 Collision

3 Oil Spill

4 Crank Case Explosion

5 ScavengeFire

6 Engine Room Fire

7 Cargo Fire

8 Abandon Ship

9 Steering Failure

10 Any Other

Experience in PMS

1 AMOS

2 TMMaster

[6 ! /10]

(E) ExperienceMatrixofDeckOfficer

Pleasemark‘Y’againstyourrankinthecell,ifthatexperienceisapplicabletoyou S.No. Description M CO 2O 3O Cdt AnyBreakdownorincidentexperience/ Remarks

Haveyousailedinthefollowingareas?

1 Indian Ocean

2 Pacific Ocean

3 North Atlantic Ocean

4 South Atlantic Ocean

5 SouthChina Sea

6 Australian Waters

7 Mediterranean Sea

8 BlackSea

9 English Channel /North Sea

10 Singapore Straits

11 Panama Canal

12 SuezCanal

13 Kiel Canal

14 Great Lakes

15

16

17

Chemical /Product Tanker Tank Cleaning experience

1 Cleanedtanksaftercarriageofveg.oil?

2 Cleaned tanksforMethanolcarriage ?

3 CleanedtanksMEGorsimilarcargoes?

4 CleanedtanksforVegOilcarriage?

5 CleanedtanksforJetFuel?

6 Changed from dirty to clean products ?

Gas Tanker Experience

1 Fully Refrigerated vessel

2 Fully pressurised vessel

3 Partially refrigerated vessel

Oil /Product /Chemical Tanker Experience

1 Inert Gas vessel

2 Crude Oil Washing

3 Inert Gas purging

4 Cleaning crudeoiltanksforhot work

5 Framo Pumps operation

6 Cargo Heating

7 Framo Pump damage

8 Over /Under pressurization of tanks

9 Cargo contamination

[7 ! /10]

Applicant’s Signature

S.No. Description M CO 2O 3O Cdt AnyBreakdownorincidentexperience/ Remarks

Bulk Carrier Experience

1 Hosetestforhatchcovers

2 Bilge valve testing

3 Ballasting of cargo hold

4 Disposal of cargo residues

5 Draft survey cargo calculations

6 Over /Under pressurization of Holds

7 Cleaned HoldsforGraincarriage ?

8 Cleaned HoldsforFertilizercarriage ?

Experience of major overhaul /breakdown

1 Drydock

2 Windlass damage /Loss of Anchor

3 Sterring Gear failure

Experience of Special circumstances &Disaster Management 1 Grounding

2 Collision

3 Oil Spill

4 Crank Case Explosion

5 ScavengeFire

6 Engine Room Fire

7 Cargo Fire

8 Abandon Ship

9 Steering Failure

10 Freezing Weather

11 Heavy weather /TRS

12 Fog /Restricted visibility

Experience in PMS

1 AMOS

2 TMMaster

[8 ! /10]

(D) Last drawn salary in USD: 500

(E) References

Please give referees from two recent employers who we may contact for references

(F)GENERAL:

I do hereby declare that all information furnished is true to the best of my knowledge and belief. Received acknowledgement of Application form

Date : Rank : Applicant’s Signature

Reference1 Reference2

Name of Company

Name of Person to contact

Address

Country

Telephone

(A

)

Have you ever been denied a foreign visa or been deported from any country? Yes / No If yes, state which country and reason (if known):

(B

)

Have you been the subject of a court of enquiry or involved in a maritime accident? Yes / No If yes, please attach details

(C

)

Have you ever signed off a ship due to medical reason within last 3 years? Yes / No If yes, please provide following details :

Nameofvessel Date of occurrence Place of occurrence Reason for sign off:

Contact this candidate