MILAHA SHIP MANAGEMENT

APPLICATION FORM MSM – OOV – SM - 151

Rank Applied LOWER POSITION ACCEPTED

DATE APPLIED DATE OF AVAILABILITY

1 . PE R S O N A L D E T A I L S
1. SURNAME FIRST NAME MIDDLE NAME

NAME
Place of
Date of Birth Nationality INDIAN
Birth
Permanent Address Present Address :
City & Pin code: City & Pin code:
Telephone Mobile Telephone
Email 1 E-mail 2
Next of Kin
Relationship Telephone
(Name)
Address of next of kin:
Nearest International Airport :
Languages
Height Weight Blood Group
Known
Marital Name of Number of
Cover All Shoe
Status Spouse Children
2 . T RA V E L D O C U M E N T D E T A I L S
Number Place of Issue Date of Issue Date of Expiry
PASSPORT
SEAMAN BOOK

3 . A C A D E MI C Q U A LI F I CA T I O N S Grade / Degree From (Year) To (Year)

School / College

Pre-sea Training
Institute
4 . LI C E N C E / C E RT I FI C A T E O F CO M P E T E N C Y
Issuing Date
Capacity Any Limitations Number Date of Issue Date of Expiry
Authority Revalidation
National
Certificate
Endorsement of
National
Certificate
Qatar
Endorsement
5 . ST C W A N D O T HE R C E RT I FI CA T E S
STCW COURSES Date of Place of
Certificate No. Date of Expiry Issuing Authority /INSTITUTE
Issue Issue
GMDSS/GOC

Rev 00 Date: 01-Apr-2018 Page 1 of 6

Master copy available with DPA. Controlled copies are in distribution as per distribution list
MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151

WATCHKEEPING CERTIFICATE FOR

RATING

ELECTRO TECHINAL RATING

PERSINAL SAFETY AND SOCIAL
RESPONSIBILITIES (PSSR)
BASIC SEA SURVIVAL / TRAINING

PERSONAL SURVIVAL TECHNIQUES

(PST)
Fire protection & Fire fighting (FPFF)
/ elementary First Aid (EFA)
ELEMENTARY FIRST AIDS(EFA)

MEDICAL FIRST AID

MEDICARE ONBOARD SHIP

PROFICIENCY IN SURVIVAL CRAFT &
RESCUE BOATS (PSCRB)
PROFICIENCY IN SURVIVAL CRAFT

ROC

ARPA
SIMULATOR TRAINING

RANSCO / RSC

SMS / NAV CONTROL

ENGINE SIMULATOR

BTM / ETM

OTHER COURSES
ILO - MEDICAL FITNESS CERTIFICATE

YELLOW FEVER

FAST RESUCE CRAFT (FRC)

TBOSIET

H2S

HUET

SHIP SECURITY OFFICER (SSO)

SECURITY FAMILARISATION
SECURITY DESIGNATED DUITES

CRANE OPERATOR

RIGGER / SLINGER
DP CERTIFICATES

DP MAINTENANCE COURSE

INDUCTION

SIMULATOR

Rev 00 Date: 01-Apr-2018 Page 2 of 6

Master copy available with DPA. Controlled copies are in distribution as per distribution list
MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151

Full /
DP OPERATOR’S LICENSE
Limited
Total DP Hrs in Total DP hrs as Junior
DP LOG BOOK DETAILS
Present Position Position

HOURS DONE WITH VARIOUS DP SYSTEM

SYSTEM DETAILS Hours as SDPO Hours as JDPO

APPROXIMATE TOTAL DP HOURS IN VARIOUS OPERATIONS

DSV/ROV

AHTS/PSV

ANY OTHER INFORMATION

6 . ME D I C A L H I ST O RY
YES NO
Have you ever signed off a ship due medical reason? X
Have you undergone any medical operations in past? X
Have you consulted a doctor during the past 12 months for an illness/Accident? X
Do you have any health or disability problem now? X
If answer to any of above is YES then give further details below or on a separate sheet

NOTE: All our clients have STRICT Alcohol and Drug Policy, which means ZERO
TOLERANCE for alcohol and drugs

7. GENERAL
YES NO
Have you ever been the subject of a court of enquiry or involved in a maritime accident? X
Have you ever had a professional license suspended or revoked? X
If yes to any of above then please fill details below or on separate sheet of paper

8 . RE F E RE N C E S ( L A ST E M P L O Y E R )
NAME OF COMPANY
Name of person to be Contacted
Address
Telephone: Mobile: Fax:
Email: Last Salary Drawn
Reason for leaving:

ANY OTHER INFORMATION, YOU WISH TO ADD IN SUPPORT OF YOUR APPLICATION

Rev 00 Date: 01-Apr-2018 Page 3 of 6

Master copy available with DPA. Controlled copies are in distribution as per distribution list
MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151

9. DECALARATION
I hereby declare that the above particulars are true and I authorize you to contact the referees listed above
and certify that the details given by me in filling up this form are true, complete, and correct to best of my
knowledge and belief. I understand that any misrepresentation or material omission made in this application
form or other documents submitted to MSM may renders me liable for termination or dismissal.

Date: 08.10.2018 SIGNATURE OF APPLICANT___________________

Rev 00 Date: 01-Apr-2018 Page 4 of 6

Master copy available with DPA. Controlled copies are in distribution as per distribution list
MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151

10. ADDITIONAL INFORMATION SHEET

Languages Spoken/Written/Understood (1-poor 5-Fluent)
LANGUAGES SPOKEN WRITTEN UNDERSTOOD

DRUG & ALOCOHOL POLICY

ALL our Clients have very strict NO DRUG and ALCOHOL POLICY, which is required to be complied with at
all times, which means “ZERO TOLERENCE on ALCOHOL & DRUG” your body must NOT have any ALCOHOL
or DRUG substances from the time you board your flight or commence your travel to join vessel, and Must
remain so until you have completed full contract and returned to your home Airport/Town
If during the said period you are found under the influence of DRUG or ALCOHOL then ALL EXPENCES
incurred which will include all your travel and recruiting costs, and your relief’s travel and recruiting costs,
and any other costs whatsoever incurred due to your NON-COMPLIANCE will be deducted from your
salary, which will include but not limited to “damage to vessel her equipment’s and machineries, loss of
charter, and other costs Directly or indirectly connected with your NON-COMPLIANCE

SIGN & CONFIRM ACCEPTANCE OF ABOVE POLICY…………………………………………

FOLLOWING DOCUMENTS COPIES MUST BE SENT TO US – send to us in separate Email

Certificate of Competency and Endorsement certificates, GMDSS/GOC certificate showing expiry date in
case of Deck Officers, DP Certificate, DP log book details, Medical Certificate, Passport and Seaman Book
FOLLOWING ADDIDITIONAL DOCUMENTS WILL ALSO BE REQUIRED
Medicare certificate, STCW 2010 endorsement certificate, ISPS Code Certificates, Ship Security Officer
(SSO) certificate. Marlin English test, Crane Operator certificate, Fast Rescue Crafts Certificate, last 3-5
years ships entries pages in Discharge book or seamen book.

Rev 00 Date: 01-Apr-2018 Page 5 of 6

Master copy available with DPA. Controlled copies are in distribution as per distribution list
 MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151
11. S E A E X P E RI E NC E : (Most recent first)
COMPANY / VESSEL PERIOD MAIN ENGINE REASON FOR
AGENTS NAME TYPE GRT DP System DP hrs RANK FROM TO M/D MAKE MODEL BHP SIGN-OFF

Please use separate sheet for any Major Incident / Observation / Special experience for reporting:

Ver 1.0 Rev 00 Date: 01-Apr-2018 Page 6 of 6

Master copy available with DPA. Controlled copies are in distribution as per distribution list