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    Indiana Maritime Private Limited: Application Form

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    This document appears to be an application form for employment at Indiana Maritime Private Limited. It requests information about the applicant's personal details, educational and technical background, identity documents, family details, certificates of competency, sailing experience, medical history, references, and includes declarations signed by the applicant. The form collects information over 17 sections to evaluate candidates for shipboard positions.

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    Indiana Maritime Private Limited: Application Form

    Uploaded by

    scribd
    25 views5 pages
    This document appears to be an application form for employment at Indiana Maritime Private Limited. It requests information about the applicant's personal details, educational and technical background, identity documents, family details, certificates of competency, sailing experience, medical history, references, and includes declarations signed by the applicant. The form collects information over 17 sections to evaluate candidates for shipboard positions.

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    Application Form 1

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    This document appears to be an application form for employment at Indiana Maritime Private Limited. It requests information about the applicant's personal details, educational and technical background, identity documents, family details, certificates of competency, sailing experience, medical history, references, and includes declarations signed by the applicant. The form collects information over 17 sections to evaluate candidates for shipboard positions.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    25 views5 pages

    Indiana Maritime Private Limited: Application Form

    Uploaded by

    scribd
    This document appears to be an application form for employment at Indiana Maritime Private Limited. It requests information about the applicant's personal details, educational and technical background, identity documents, family details, certificates of competency, sailing experience, medical history, references, and includes declarations signed by the applicant. The form collects information over 17 sections to evaluate candidates for shipboard positions.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 5

    INDIANA MARITIME PRIVATE LIMITED

    RPSL NO: MUM 416 Validity: 25/01/2022


    Office no-405, 4th Floor, Mayuresh Cosmos, Sector-11, CBD Belapur,
    Navi Mumbai 400614. Ph-022-49744554 , EMAIL ID:[email protected]

    PHOTO
    APPLICATION FORM
    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? YES/NO
    Are you responding to a media advertisement ? If YES, please state which publication YES/NO
    From ehat date will you be availbale ?

    2 Personal details

    Name: (Surname)
    (First Names)
    (Middle Name)
    Date/Place of Birth: Nationality:

    Pin Code:
    Permanent address: E-Mail: Tel No: Mobile
    Pin Code:
    Local address: E-Mail: Tel No: Mobile

    3a Educational Background
    Qualification 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: INDIAN
    Seaman Book: National
    Panamanian
    Liberian
    Others
    Do you hold a US Visa 'C1/D'? YES/NO Issue Date: Expiry Date:
    Do you hold a US Visa 'B1/B2'? YES/NO Issue Date: Expiry Date:
    Have you been rejected for any visa applied for? YES/NO
    If YES, please state the country and reasons
    INDOS No: (only for Indians) YELLOW FEVER V/T:
    MUI NO: V/T

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


    DATE
    DATE
    PASSPO PLACE OF OF
    NAME Relation DOB POB OF ECNR
    RT NO. ISSUE EXPI
    ISSUE
    RY
    IMPL/01 1-Mar-18 Rev-1

    6 Certificate (Highest certificate of competency held)

    Date of Passing Certifica


    Grade / Class Issuing Country Date Issued Place Issued Valid Until
    Exam te No.

    7 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
    Panama
    Others
    8 Details of Courses
    Courses Certificate No. Issued by Date Issued Date of Expiry
    FPFF / AFF
    EFA / MFA / MEDICARE
    PSCRB
    PST

    PSSR - Personal Safety & Social Responsibilities

    SSO - Ship Secruity Officers Course


    ISPS Course
    ROSC - Radar OBS Simulator
    ARPA - Automatic Radar Plotting Aid
    RANSCO - Radar, Arpa & Navigation Similutor
    BTM
    SMS / SHS / ERS
    Bridge & Engine Resources Management
    Ship Master Command and Control Course
    GMDSS : endorsement
    RUTC - Refresher & Upgradation Course
    Container Operations / Hazmat
    Electrical Familiarixation for Marine Engineers
    Electronics for Marine Engineers
    Instrumentation & Shipboard Control Systems
    Automation and Controls
    container Refrigeration
    Hydraulics for Engineers (Basic / Advance)
    Container Operations and Hazmat
    Hydraulics and Pneumatics Workshop
    Watch Keeping Certificate Ratings
    (Deck/Engine)
    Applied Electronics (AELC)
    Practical Marine Electrical Workshop
    Engine Equipment Maintenance Workshop
    Basic Electrical and Fluid Technology
    Reefer Container and Maintenance Course
    MEPC
    Operational Competence enhancement course for
    deck officers
    Safety, Environment Compliance & Pollution
    Prevention Training for Crew
    IMPL/01 1-Mar-18 Rev-1

    10 For Engineers (Please Provide details)

    Generators

    Purifirs and Boilers

    Type of Cranes / No of
    Reefer Containers

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

    Container PCC Reefer Multi Purpose Others

    LAST SALARY DRAWN (PLEASE MENTION CURRENCY)

    12 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)

    13 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)

    14 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

    Tel No.

    15 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

    16 Declaration

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

    17 BOILER SUIT SIZE: SAFETY SHOE SIZE:

    IMPL/01 1-Mar-18 Rev-1


    ade

    IRY

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