Application Form: Date: 30-Dec-1899
Application Form: Date: 30-Dec-1899
Application Form: Date: 30-Dec-1899
7 Correspondence Address
& Contact Details : City State Country Zip Code
STD Code Res. Fax: Mobile: Email
10 Name Relationship
Next of Kin - [ Name ,
Address & Contact Details] City
State Country Zip Code
Std. Code Res. Fax: Mobile: Email
11 Name
Emergency Address
[If family onboard] City
State Country Zip Code
STD Code Res. Fax: Mobile: Email
Rev:01 Page 1 of 36
Date of Date of Place of Issue Nat-
13 Seaman Book [ C.D.C ] Number
Issue Expiry (Country) ional
No
No
No
No
No
No
No
Other visa
14
Name Place of Issue Date of Issue Date of Expiry
Note: Details of any more courses / certificates other than the above may be included below in box No. 18 - [SUMMARY]
PREVIOUS SEA EXP. [ Datewise upto 10 previous vessels in ascending order ] ie : End with your last vessel served
Engine Manning Agts /
16 Vessel Name Flag Type Dwt GRT Bhp Rank From To UMS TEUs
Type Owners Name
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Note : Eng. Officers and Elec.Officers to indicate UMS experience
17 SUMMARY OF KNOWLEDGE AND EXPERIENCE ACQUIRED [Give a brief resume of your Career and Experience at
Sea, e.g. Type of Ships, Engines, Specific Trades (E.G. ICE / Lighterage etc.),
reactivation, New Buildings, Shore Experience, Computer Knowledge etc.]
REFERENCES:
19 Title Name Company Name Phone Number
A
Address
A
B
LANGUAGES
20 LANGUAGE Spoken Written Read OTHER [specify] Spoken Written Read
ENGLISH
PHYSICAL DECLARATION
21 VISION Excellent Good Poor HEARING Normal Poor Nil
With Glasses Right Ear
Without Glasses Left Ear
Height (cms) Hair [colour] Identification Mark on body [if any]
Weight (kgs) Eyes [colour]
a Are you involved in any marine accident/investigations? [Collision/Grounding/Fire/Pollution] ? If yes please give details
b Did you suffer any accident which rendered you temporarily and / or partially disabled ? If yes please give details.
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c Are you currently under medical treatment or taking medication for existing conditions? If yes please give details
d Did you suffer , or do you presently suffer from any diseases likely to render you unfit for sea service or likely
to endager the health of other persons onboard ?
27 DECLARATION
I 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 Bernhard
Schulte Shipmanagement Pvt. Ltd. may renders me liable for termination or dismissal. Personal information regarding myself may be
shared for operational reasons within the companies of the BSM group and with concerned Ship Owner(s).
Rev:01 Page 4 of 36
Satisfactory
Poor
Rev:01 Page 5 of 36
CANDIDATES SUMMARY OF KNOWLEDGE AND EXPERIENCE CONTD.
SUMMARY OF KNOWLEDGE AND EXPERIENCE ACQUIRED [Give a brief resume of your Career and Experience
at Sea, e.g. Type of Ships, Engines, Specific Trades (E.G. ICE / Lighterage etc.), reactivation, New Buildings,
Shore Experience, Computer Knowledge etc.]