Figure 03 - CV - Sea Staff Application Form
Figure 03 - CV - Sea Staff Application Form
PHOTO
3rd ENGINEER
1. PERSONAL DETAILS
TITLE MR/MRS/MISS
MR
SEX
MALE
FEMALE
SURNAME
NARE
FIRST NAME
GAURAV
OTHERS NAMES
DATE OF BIRTH
15 FEB 1985
PLACE OF BIRTH
MUMBAI
NATIONALITY
INDIAN
MARITAL STATUS
UNMARRIED
COLOUR OF EYES
BLACK
COLOUR OF HAIR
BLACK
MOTHERS NAME
VARSHA NARE
FATHERS NAME
VILAS NARE
173
WEIGHT (KG)
73
2. ADDRESS
MUMBAI
NO & STREET
18/803,SAFFRON,REGENCY
ESTATE,KALYAN SHIL ROAD
NO & STREET
CITY
DOMBIVLI EAST
CITY
POST CODE
421203
POST CODE
COUNTRY
INDIA
COUNTRY
TEL. NO.
TEL. NO.
MOBILE
7738821243/7506364819
MOBILE
FAX
FAX
3. NEXT OF KIN
FULL NAME
RELATIONSHIP
ADDRESS
FATHER
Mideast: 025
FLEET PERSONNEL ADMINISTRATION
CITY
COUNTRY
DOMBIVLI
TEL. NO.
MOBILE
INDIA
FAX NO.
9967764819
4. CHILDREN
FULL NAME OF CHILD
DATE OF BIRTH
SEX
M
5. TRAVEL DOCUMENTS
TYPE
DOCUMENT NO.
ISS.DATE
EXP. DATE
ISS. BY (AUTHORITY)
PASSPORT
G 2091699
21/02/2007
20/02/2017
INDIA
THANE
PLACE OF ISSUE
SEAMAN BOOK
MUM 148259
13/02/2009
12/02/2019
INDIA
MUMBAI
MH 368136
01/08/2014
21/07/2019
MARSHALL ISLAND
VIRGINIA,USA
US C1/D VISA
H8817629
26/12/2013
23 /12/2018
USA
MUMBAI
OTHER VISAS
AXIS BANK
BRANCH
DOMBIVLI EAST
CITY
DOMBIVLI
COUNTRY
INDIA
SORT CODE
UTB0000125
BANK ADDRESS
ACCOUNT NO
BANK TEL. NO
060010100388054
0251-2800671
7. EDUCATION
SCHOOL NAME
FROM
1989
TO
2001
SCHOOL NAME
FROM
TO
NUMBER
ISSUE DATE
EXPIRY
DATE
ISSUED BY
(AUTHORITY)
ISSUED AT
CL IV INDIA
95Z-12416
08/12/2010
06/02/2020
INDIA
MUMBAI
NUMBER
ISSUE DATE
EXPIRY DATE
PETROLEUM
M/0/2/E/12/19856
29/08/2012
31/12/2016
CHEMICAL
M/C/1/E/13/23280
05/06/2013
31/12/2016
GAS
9. LANGUAGES
Mideast: 025
FLEET PERSONNEL ADMINISTRATION
ENGLISH
FLUENT
GOOD
FAIR
POOR
GERMAN
FLUENT
GOOD
FAIR
POOR
FRANCH
FLUENT
GOOD
FAIR
POOR
SPANISH
FLUENT
GOOD
FAIR
POOR
ITALIAN
FLUENT
GOOD
FAIR
POOR
RUSSIAN
FLUENT
GOOD
FAIR
POOR
ISSUED DATE
RESULT %
ISSUED BY (AUTHORITY)
ISSUED AT
ISSUE
DATE
NUMBER
EXPIRY
DATE
ISSUED BY
(AUTHORITY)
ISSUED AT
INTERNATIONAL
LIBERIAN
NORWEGIAN
PANAMANIAN
NAME
YELLOW FEVER
ISSUE DATE
EXPIRY DATE
ISSUED BY (AUTHORITY)
ISSUED AT
04/12/2018
INDIA
MUMBAI
5/12/2008
BOOTS SIZE
XL
NUMBER
SGA/PST/2007-802-10537
ISSUE
DATE
EXPIRY
DATE
ISSUED BY
(AUTHORITY)
ISSUED AT
22-12-2007
21-12-2012
SAGAR GYAN
MUMBAI
FPFF/8006/2008
12-01-2008
11-01-2013
OERC ACADEMY
MUMBAI
BPMA/AFF/RF/181/2015
27.01.2015
26.01.2020
BP MARINE
MUMBAI
27.12.2012
EFA/2825/2007
28.12.2007
OERC ACADEMY
MUMBAI
BPMA/ENGR-UP/28/2015
07.02.2015
BP MARINE
MUMBAI
BPMA/ENGR-UP/28/2015
07.02.2015
BP MARINE
MUMBAI
RPSCRB C/B44/03
31.01.2015
HIMT
CHENNAI
OIL TANKER
BPMA/TFC/829/2008
14.11.2008
BP MARINE
MUMBAI
BPMA/ATOT/453/2011
15.10.2011
BP MARINE
MUMBAI
BPMA/CTFC/894/2008
21.11.2008
BP MARINE
MUMBAI
STC/02/13/032
29.03.2013
CHEMICAL TANKER
ADVANCE CHEM ANKER
GAS TANKER
ADVANCE GAS TANFC/KER
MASSA
MUMBAI
Mideast: 025
FLEET PERSONNEL ADMINISTRATION
STS/55/13/1120
20.12.2013
MASSA
MUMBAI
ISSUE
DATE
NUMBER
EXPIRY
DATE
ISSUED BY
(AUTHORITY)
FROM
TO
COMMENTS
NEW BUILDING
SPECIALISED PROJECTS
SPECIAL TRADES
SHORE EXPERIENCE
ISSUED AT
COMPANY NAME
RANK:
RANK
SIGNED
VESSEL NAME
ON
AVALIABILITY
DATE:07 JULY
2015
ONWARDS
3/E
SIGNED
OFF
PERIOD
IN
MONTHS
TYPE OF
VESSEL
(eg 4.2)
NAVIG8 SHIP MGMT
NAVIG8 SHIP MGMT
NAVIG8 SHIP MGMT
GENMARCO
SOVEREIGN SAFESHIP
FIVE STAR SHIPPING
3/E
3/E
4/E
4/E
4/E
5/E
21.05.2014
23.11.2014
6.1
M.T.ZHONGJI NO.2
18.03.2014
05.05.2014
1.7
M.T.ZHONGJI NO.1
20.06.2013
05.12.2013
5.5
20.10.2011
28.01.2011
24.03.2009
01.04.2012
18.05.2011
09.11.2009
Product Tanker
Oil Chem Tanker
Oil Chem Tanker
5.5
3.7
Oil Tanker
7.6
Bulk carrier
Product Tanker
ENGINE TYPE
D.W.T.
( ENGINEERS
ONLY)
ADDRESS
PHONE NO.
FAX/E-MAIL
CONTACT PERSON
MR.AJIT KESARKODI
DATE
KW
MAN B&W
11610
8530
WARTSILLA
12730
9360
WARTSILLA
12730
9360
MAN B&W
13510
9930
HANSHIN
4500
3300
SULZER
11550
8490
BHP
SIGNATURE
Ref .No
Medical History
Have you ever signed off from a ship due to medical reasons?
*yes/no
Date of occurrence
(dd-mmm-yyyy)
Name of Vessel
Details
Have you ever suffered from any ailment or disease in the past that is likely to render you
unfit for sea service or likely to endanger the health /well being of others onboard?
(If Yes give details)
*Yes/No
Details
*Yes/No
Details
Are you currently suffering from any ailment or disease that is likely to render you unfit for
sea service or likely to endanger the healthy /well being of others onboard?
(If Yes give details)
*Yes/No
Details
*Yes/No
Details
Are you suffering from an ailment that requires you to be on a long -term
treatment/medication?
(If Yes give details)
*Yes/No
Details
*Yes/No
Details
Have you ever been convicted of a criminal or drug offence or have any pending offences?
(If Yes give details)
*Yes/No
Details
*Yes/No
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. I also
certify that my medical history contained above is true and any false statement or undisclosed Material information about
past illness or injury will disqualify me from any employment benefits and claims.
..
dd-mmm-yyyy (Format)
..
Signature