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APPLICATION FORM

Position applied for : MARINE SUPERITENDENT Nationality : INDIAN

Surname :SAMBHI Availability Date :last WEEK of 0ct 12

Forenames:SURINDERJIT SINGH Maritial status : Married

Telephone No. / Email ID09811399523 zn608o@r.postjobfree.com Address :11/363 SUNDER VIHAR,NEW DELHI-PIN CODE 110087

Date & Place of Birth :05.07.54/JALLANDER

Next of Kin: MRS MINISAMBHI Relation:WIFE

Address : AS ABOVE

Telephone No . / Email ID 919*********/981******* zn608o@r.postjobfree.com

Guardian (When NOK an board )

Address :

Telephone No. / Email ID

Name of Father:JAGJIT SINGH SAMBHI Name of Mother DILJIT KAUR

Name of Wife: MINI SAMBHI Nationality INDIAN

Date of Birth: 09.05.64 Passport No:E7989843 Place of Issue:DELHI Date of Expiry:18.-3.14

Documents Number Date & Place Issued Expiry date

Passport G1286708 10.01.07/DELHI 09.01.17

CDC ( National ) BY52034 11.04.80/MUMBAI 17.07.11

U.S.Visa C1/D -- 22.02.07 30.01.12

National Lic . Class 1 / Class 2 / OOW * IF003295 13.07.06 21.06.16

QUALIFICATIONS

Academic Background

Name of Institution City + Country From To Qualification Obtained Grade / Percentage

SCI INDIA 1972 1976 CADET

Presea Training

Institute From To

Sr Name of Children D.O.B Sex Passport No Place of Issue Date of Issue Date of Expiry

1 SIMRANJIT SINGH 31.07.87 M E7989973 DELHI 22.03.04 21.03.14

2 SUDARSHANJIT 06.12.88 F E7989994 DELHI 22.03.04 21.03.14

S.No Type of Documents Number Place of Issue Date of Issue Date of Expiry

1. PST/PSCRB * PSC2132 MUMBAI 19.06.91

2. FPFF / AFF * 013471 UK 13.12.84

3. PSSR PR980240 DELHI 05.08.98

4. Medicare / MFA / EFA* MC/A/133 MUMBAI 13.06.91

5. Medical Examination

6. D & A Test

7. Yellow Fever 85447 DELHI 22.07.08 21.07.18

8. U.S.Visa CI / D

9. Union / Card / Dues AWAITING NEW CARD

10. Indos No. 00NL4270 MUMBAI 22.06.01

11. Radar Observer / ARPA 243 MUMBAI 21.06.91

12. Radar Simu / Ransco 010528 MUMBAI 14.07.91

13. GMDSS ( National ) GG3439 UK 15.11.96 21.06.16

14. GMDSS Endorsement

15. Ship Security Officers Course 755/02008/00423 DELHI 31.12.08

16. MRM Course * (Tnkr / Sr. Off)

17. BTM Course*(Tnkr / Sr.Off) AE/BTM/OXV/011 DELHI 12.07.08

18. Flag Lic. Grade …

19. Flag CDC

20. Flag GMDSS

21. Tanker Co. Ops / Mng * 84/517 UK 21.12.84

22. Nat. DCE (Pet ) O/M *

23. Flag DCE - Oil

24. Chem Co. Ops / Mng * 040043 MUMBAI 25.02.04

25. Nat . DCE (Pet) O/M* D/0/2/D/11/9924 DELHI 21.07.11 24.05.15

26. Flag DCE – Chem D/C/2/D/09/4848 DELHI 16.01.09 15.01.14

27. Gas Co. Ops/ Mng *

28. Nat DCE (Gas) O/M*

29. Flag DCE - Gas

30. Tanker vetting insp.

31. Simulator Emgine / Ship* SMS/NDG/07006 DELHI 27.01.07

32. Liq. Cargo Simulator

33. Pre – Sea Course

34. Flag Lic. Grade

35. Flag CDC

¬¬PREVIOUS SEA EXPERIENCE (FOR LAST FIVE YEARS OR 10 SHIPS SERVED)

Vessel’s Name Deck Trade & DWT OR Engg Type & BHP Type of Vessel Company’s Name Rank Period Dates

From - To Months / Days

Reason for s/off

SMYRNI 144999 CRUDE DYNACOM MASTER 23.11.11 TO 01.02.12 2-15/COC

TORM CHARENTE 37850 PROD/CHEM TORM MASTER 10.02.11-

26.05.11 3-15/COC

TORM CECILIE 45999 PRODUCT/CHEM TORM MASTER 15.11.10-15.01.11 2-00/COC

JAG LYALL 101500 CRUDE GESCO MASTER 15.01.10-25.05.10 04-26/COC

JAG LATEEF 125000 CRUDE GESCO MASTER 18.07.09-15.09.09 02-00/COC

ICE FIGHTER 88000 CRUDE DYNACOM MASTER 14.04.09-24.06.09 02-15/COC

FEDREL II 96170 CRUDE VSHIPS MASTER 18.07.08-27.10.08 03-15/COC

JAG LAXMI 140,000 CRUDE GESCO MASTER 15.01.08-06.04.08 02-23/COC

SUNRISE 265000 CRUDE DYNACOM MASTER 06.02.07-22.06.07 04-16/COC

ENDEAVOR ** 80000 CRUDE PROSAFE MASTER 12.09.06-14.11.06 02-00/COC*

HUDSON 136000 CRUDE DYNACOM MASTER 17.09.05-07.02.06 04-20/COC

DIFKO BIRTHA 88000 PRODUCT SELANDIA MASTER 27.04.04-13.06.04 1-16/COC

DIFKO BIRTHA 88000 PRODUCT SELANDIA MASTER 28.05.03-29.11.03 6-01/COC

SITACAMILLA 88000 PRODUCT SELANDIA MASTER 20.09.02-26.12.02 03-16/COC

SITAMIA 88000 PRODUCT SELANDIA MASTER 27.04.02-22.07.02 03-21/COC

SITAKATHRINE 88000 PRODUCT SELANDIA MASTER 24.08.01-23.06.01 05-06/COC

Last Employer: name, PIC & Contact No.:CAPT V IPAN TALWAR 919*********

Summary of Sea going Experience

Period served on (yy/mm)

B/C Cape S CNTR P/ Tanker Chem VLCC LPG Framo

22YRS09MONTHS 05YRS 112MONTHS 33YRS

*REMARKS: HAVE WORKED ON FSO FOR 1 YEARS OFF MADRAS on M.T Endeavour

For Engineer Officers only :

Period served on ( yy / mm )

Sulzer B & W MAN Pielstick UEC Doxford Steam UMS C / p prop Cranes

Nationality of crews sailed with : INDIAN,PHILLIPINE,BANGLADESH,PAKISTANI

Are you familiar with computer operation ? Please specify. YES

Are you familiar with computer based PMS ? Please specify . YES

Attached to vessels during : ALL

Drydockings :5YRS New Construction :NIL Major ConversionNIL

Incidents of Grounding / Fire / Explosion / Collision / Abandon Ship / Rescue /

Major oil Pollution / Drug Smuggling / Towed or Towing another vessel NO

Were you ever involved in a court of Enquiry for a Maritime accident ? NO

Have you ever missed your ship or left behind in port ? NO

Has your present or previous certificate ever been suspended / revoked ? NO

Have you ever been involved in a criminal proceeding : If yes on any of the above, give details: NO

Medical History & Declaration Height 176CM Weight98KGS Blood Group+B

Do you suffer or have suffered from : Diabetes / High Blood Pressure / Hepatitis / Epilepay / Nervous Disorders/ Disturbed Vision Or Hearing / Vertigo If yes, give details : NO

Are you a habitual user of Drugs / Narcotics / Excessive Alcohol : NO

Are you aware of any aliment that would make you unfit for sea services : NO

Leisure Time activity / Games/ Hibbies ; During School / College / Sea Service HOCKEY/CRICKET

Declaration to be made and signed by Applicant :

I understand that a strict medical examination including Drug and Alcohol test as per company requirements is a a condition of my employment and I express my willingness to be examined. I undertake to provide the company’s medical officer full details of my previous medical history. I agree that the decision of the company medical officer is final.I confirm that all my travel documents are valid and in order. I understand that if my travel Documents at any time during the course of my employment become invalid or restricted and cannot be revalidated by me under normal process, making further travel or service by me is not possible, the contract of employment stands subject to cancellation and all costs of repatriation will be borne by me .I am /am not presently employed elsewhere and if my application is successful, I will be available to report w.e.f. :

Name of Applicant SURINDERJIT SINGH SAMBHI Rank MASTER

Date 10.03.09 At DELHI

Signature of the Applicant S.S.SAMBHI

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