SEASTAR SHIP MANAGEMENT PRIVATE LIMITED

APPLICATION / PERSONAL DATA FORM FOR OFFICER’S & RATINGS

1

1

Position ID/PD No. (For Office Use Only)

Position applied for:

Are you willing to accept any other positions? If YES, which positions would you consider? NO

YES/NO

Are you responding to a media advertisement? If YES, please state which publication NO

YES/NO

From what date will you be available? Negotiable

2

Personal details

Name:

(First Name) ANUMAY

(Middle Name)

(Last Name) RAYCHAUDHURI

Date / Place of Birth:

05.01.1966/HOWRAH

Nationality:

INDIAN

Permanent address:

13B,BADAL BOSE SARANI,HOWRAH.WEST BENGAL.’LEMON TREE’FLAT4B,BLOCK-B

Pin Code:

E-Mail:

adp7os@r.postjobfree.com

(Tel No. :

Mobile

098********

Local address:

Same as above

Pin Code:

E-Mail:

(Tel No.

Mobile

070********

3a

Educational Background

Qualification

Higher Secondary Science

School / College

From

To

Percentage/ Grade

3b

Technical Background

Degree/ Diploma

Institute/ College

From

To

Percentage / Grade

4

Identity documents

DOCUMENT

COUNTRY

NUMBER

DATE OF ISSUE

PLACE OF ISSUE

DATE OF EXPIRY

Passport:

INDIA

T2220902

19.03.2019

KOLKATA

18.03.2029

Seaman Book:

INDIA

CL45646

14.11.1994

KOLKATA

27.05.2014

Other SBK

Do you hold a US Visa ‘C1/D’?

YES/NO

NO

Issue Date:

Expiry Date:

Do you hold a US Visa ‘B1/B2’?

YES/NO

NO

Issue Date:

Expiry Date:

Have you been rejected for any visa applied for?

YES/NO

NO

If YES, please state the country and reasons

INDOS No: (only for Indians)01XL0406

YELLOW FEWER V/T:02.09.2020

MUI NO : V/T

5

Family Details: (If Unmarried kindly give details of Father / Mother)

NAME

Relation

DOB

POB

PASSPORT NO.

PLACE OF ISSUE

DATE OF ISSUE

DATE OF EXPIRY

ECNR

SOMA RAYCHAUDHURI

WIFE

10.09.1973

HOWRAH

T1068216

KOLKATA

28.02.2019

27.02.2029

6

Certificates (Highest certificate of competency held)

Grade/Class Of COC Country

Issuing Country

Date of Passing Exam

Certificate No.

Date Issued

Place Issued

Valid Until

REETO

INDIA

06.02.2007

SMC/REETO/030

06.02.2007

KOLKATA

NA

7

Dangerous Cargo Endorsements Details

Type

Certificate No.

Date Issued

Place Issued

Valid Until

OIL

CHEMICAL

GAS

8

Certificates Of Competency issued by other countries (Issued by countries other than in Section 6)

Issuing Country

Certificate No.

Date Issued

Place Issued

Valid Until

9

Details of Courses

Courses

Certificate No.

Issued By

Date Issued

Date Of Expiry

FPFF / AFF

002999

IIPM

19.05.2000

NA

EFA / MFA / MEDICARE

MFA0140000307

MMA

04.05.2000

NA

PSCRB

00382

MMA

16.06.2000

NA

PST

PSSR – Personal Safety & Social Responsibilities

SCMS/PSR/192/98

SCMS

30.09.1998

NA

SSO – Ship Security Officers Course

00838

IIPM

24.08.2005

NA

ISPS Course

ROSC – Radar OBS Simulator

ARPA – Automatic Radar Plotting Aid

RANSCO – Radar, Arpa & Navigation Simulator

BTM

SMS / SHS / ERS

Bridge & Engine Resources Management

GMDSS

GG10510

MCA

05.08.1997

28.10.2015

GMDSS Endorsement

Refresher & Upgradation Course

Container Operations / Hazmat

Electrical Familiarization for Marine Engineers

Electronics for Marine Engineers

Instrumentation & Shipboard Control Systems

Automation and Controls

Container Refrigeration

Hydraulics for Engineers (Basic / Advance)

Hydraulics and Pneumatics Workshop

Applied Electronics (AELC)

Practical Marine Electrical Workshop

Engine Equipment Maintenance Workshop

Basic Electrical and Fluid Technology

Reefer Container and Maintenance Course

Watch Keeping Certificate Ratings (Deck/Engine)

Oil Tanker Safety Course

Chemical Tanker Safety Course

Gas Tanker Safety Course

10

9

Record of previous service

(Please give a full record starting with the last vessel on which you served)

COMPANY

VESSEL NAME

VESSEL TYPE

D.W.T

GRT

VSL AGE

TYPE OF ENGINES

(Please give full dtls)

B.H.P

RANK

SIGN ON dd/mm/yy

SIGN OFF dd/mm/yy

DURATION yy/mm/dd

REASONS FOR S/OFF

Thome

M.T.Riverside

TNC

62856

2

BNW

19380

E/O

11.02.11

17.09.11

7M10D

Thome

M.T.Hero 1

TNC

169187

10

BNW

36927

E/O

19.12.10

15.01.11

26D

Great Eastern

M.V.Jag Vikram

BC

16910

30

SULZER

11550

E/O

04.04.10

19.06.10

2M18D

Torm

M.T.Torm TTThames

TNC

29214

4

MANBNW

15820

E/O

04.06.09

07.08.09

2M3D

Torm

M.T.Torm Garone

TNC

23246

4

MANBNW

15050

E/O

25.10.08

04.03.09

.

4M8D

Ocean Tanker

M.T.Ocean Vela

TNC

37708

28

SULZER

11179

E/O

20.02.08

06.08.08

.

5M17D

Grand Seatrade

M.V.Grand Clipper

BC

85286

12

BNW

16858

E/O

27.04.07

08.09.07

4M11D

Anglo Eastern

M.T.Heidmar Brazos

TNC

44871

25

BNW

2x6700max

Tr.Prsr

23.11.05

27.04.06

5M6D

K-Line

M.T.Grace River

LPG

44673

2

BNW

20630

CLRK

26.06.04

21.12.04

5M26D

APJ Line

M.V.APJ Akhil

BC

27997

6

BNW

11700

R/O

25.08.01

16.02.02

5M22D

Tradeline

M.V.Accord 1

GC

12278

27

DOXFORD

12000

R/O

04.12.00

08.05.01

5M6D

Douss

M.V.Nita1

BC

10572

27

BNW

7420

R/O

26.04.99

14.10.99

5M19D

SCI

M.T.L.M.Tilak

TNC

47690

23

BNW

20300

R/O

05.03.98

12.06.98

3M8D

SCI

M.T.R.Prasad

TNC

59652

24

BNW

20300

R/O

30.01.97

16.10.97

8M17D

APJ Line

M.V.APJ Priti

BC

10371

23

MITSHUBISHI

8000

R/O

08.10.96

18.01.97

3M11D

SCI

M.V.Nicobar

PAX

14195

11

SULZER

2x2607

R/O

21.02.96

19.08.96

5M10D

APJ Line

M.V.APJ Priti

BC

10371

23

MITSHUBISHI

8000

TR/O

20.11.94

14.07.95

8M24D

11

For Engineers (Please provide details)

Generators

Purifiers and Boilers

Type of Cranes / No of Reefer Containers

12

Sailing Experience: (Please advise PRESENT RANK EXPERIENCE on each type of vessel)

BULK / M P V

Reefer / Container / PCC

Oil / Chemical

VLCC / Crude

Others

LAST SALARY DRAWN (PLEASE MENTION CURRENCY)

13

Medical history

Have you ever signed off a ship due to medical reasons?

YES/NO

Have you undergone any operation in the past?

YES/NO

Have you consulted a doctor during the last 12 months for an illness/accident?

YES/NO

Do you have any health or disability problems now?

YES/NO

(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)

14

General

Have you ever been the subject of a court of enquiry or involved in a maritime accident?

YES/NO

Have you ever had a professional license suspended or revoked?

YES/NO

(If YES, please give full details and attach a separate page if necessary)

15

References (Please give the name and address of your current or immediate past employer)

Name of company

1.

2.

Name of person to contact

Address

( No.

16

Review

If immediate employment is not available do you wish to be considered for future vacancies?

YES/ NO

If YES, please give any alternative contact details not shown in Section 2

17

Declaration

I hereby declare that the above particulars are true and authorise you to contact the referees listed above.

Date:

Signature

18

BOILER SUIT SIZE: SAFETY SHOE SIZE: HEIGHT: WEIGHT:

PHOTO

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