RYAN SHIP MANAGEMENT LTD

SHIPPING CONNECTIONS / (MARITIME RECRUITMENT)

POSTAL ADDRESS:-RYANSHIP P O Box 1282 - SUNDERLAND TYNE and WEAR SR5 9HX UNITED KINGDOM Tel: +44 191 54 888 59 Fax: +44 191 54 88 425 Email : [email protected] www.shipping-connections.com

Application Form
Section 1
Position Applied for Lowest Position Acceptable Date of Availability

Deck & Engineering Officers

Position
TUG CH/OFF 23 /09 / 2011 MUST Enter a date and in dd/mm/yyyy

Section 2
Family name / Surname First Name / Given Name Date & Place of Birth Nationality Permanent Address Present Address PPE information Present Contact Number Mobile Number SKYPE ADDRESS Email Address Nearest Airport (and Distance)

Personal Details
SHUKLA LAXMI NARAYAN Date 10.05.1978 Place- SULTANPUR INDIAN VILL- BHIKHIPUR POST PINDARA (MUSAFIRKHANA) DISTK. C. S.M. NAGAR (SULTANPUR) UTTER PERDESH227815 VILL- BHIKHIPUR POST PINDARA (MUSAFIRKHANA) DIST.- C.S.M. NAGAR (SULTANPUR) UTTER PERDESH 227815 SAFETY SHOES SIZE 08 NO COVERALL SIZE XL 09699692761 09699692761, 07874129599 HOME 9451296715 [email protected] MUMBAI INDIA 25.09.2002 LUCKNOW E-3322141 24.09.2012 [email protected]

Section 3
Country of Issue Date Issued Place Issued Passport Number Passport Expires
Secondary passport or Dual nationality

Passport and VISA details

USA Visa - Type B1/OCS USA VISA Expires USA Visa - Type C1/D USA VISA Expires Other Country Visa Visa Expiry

WPIF M/01

12TH July 2011

Rev - 02

Section 4 ( hi-light as required )

Issuing Country & Place Number

Seaman book / Discharge book / Seaman Record Book / CDC INDIA MUMBAI MUM -140723
BIMLESH SHUKLA FATHER, MOTHER.

Date Issued Expiry Date (if any)

15.02.2007 14.02.2017

Section 5
Full Name / Relationship
Any dependents / Children (incl age )

Next of Kin this is important information we require- Dont ignore it

WIFE / CHILD 01 RISHAV SHUKLA AGE 06

Address Contact Numbers

009451296715

VILL- BHIKHIPUR POST PINDARA (MUSAFIRKHANA) DIST.- C.S.M. NAGAR (SULTANPUR) UTTER PERDESH 227815

09451296715 Section 6 STCW95

Class / Grade/Capacity

Page 1 of 7
Highest Certificate of Competency / Licence Held ( also list Flag State Endorsements)
Certificate No.

Issuing Country

Date Issued

Expiry

Details of Limitations

IV 2nd Class Master

INDIAN 293/2007 (KOLKATA)

18.12.2007

----

INLAND VESSEL

ALSO ENTER ABOVE DETAILS OF ANY OTHER FLAG STATE CERTIFICATES HELD

Section 7

STCW95
--

Dangerous Cargo Endorsements

Date Issued
--

Petroleum.
Liquefied Gas. Liquid Chemicals.

Certificate No.

Expires

Details of Limitations/ Grade

Section 8

STCW95 related Courses Attended and Certificates Obtained

STCWCode

Name of Course / Certificate

Personal Survival Techniques Basic Sea Survival / Training Fire Prevention & Fire Fighting Elementary First Aid
Personal Safety & Social Responsibility Proficiency in Survival Craft & Rescue Boats

Place NAVI MUMBAI NAVI MUMBAI NAVI MUMBAI NAVI MUMBAI

Issue Date 14.02.2002 04.12.2002 07.12.2002 11.12.2002

Cert No
BPMA/PST/1472/2 002

Expir Date

A- VI/1-1 A-VI/1 A-VI/1-2 A-VI/1-3 A-VI/ 1-4 A-VI/ 2-1 A-VI/ 3 A-VI/ 4-1 A-VI/4-2 A-II/ 1-2 A-IV/ 2

Proficiency in RESCUE CRAFTS Advanced Fire Fighting Medical & First Aid Medical Care ( Ship Captains Medical Course ) Radar & ARPA Simulator TrgManagement level GMDSS + ENDORSEMENT SAFETY OFFICERS COURSE (SO)

WPIF M/01

12TH July 2011

Rev - 02

Ship Security Officers Course (SSO) Issued under STCW95 Medical Certificate / HEALTH Certificate Drug and Alcohal test certificate YELLOW FEVER Bridge Team Management Bridge Resources Management Electronic chart Display and Information System course ( ECDIS ) ISM Code TANKERS FAMILIARISATION Advanced Tanker Operations (Chem.) Advanced Tanker Operations (Oil) Advanced Tanker Operations (LPG) INERT GAS CRUDE OIL WASHING Tanker Safety ( petroleum ) Tanker Safety ( Chemical ) Tanker Safety ( GAS ) REFRESHER & UPDATING Other ???? Other ???? Other ???? Other ????

A-VI/ 5

A-II/2 B-VIII/2

A.1441 (18)

A-V/1 A-V/1-2 A-V/1 A-V/1

I/II & III/2

Page 2 of 7
L I S T A L L O T H E R C O U R S E S

Section 9
Name of Course / Certificate
BOSIET HUET FOET OFFSHORE MEDICALS ( UK, NORWAY or NETHERLAND )

OFFSHORE INDUSTRY COURSES

APPROVALS Place Issue Date Cert No Expiry

Please enter below any other certificates held or courses done, ie offshore, DP certs etc or Any other not already mentioned

Re-Breather training
Initial Standby vessel crews training ( ITSO ) CAA (Civil Aviation Authorities Helicopter)

Advanced Medical Aider ( AMA ) HLO MARLINs English Test IELTS-English TEST

Score:

% SCORE

http://www.ielts.org/test_centre_search/search_results.aspx

PMS maintenance system Confirm that you are Familiar with its use ( YES / NO )

WPIF M/01

12TH July 2011

Rev - 02

DEEP WATER ANCHOR HANDLING EXPERIENCE DP Maintenance Courses DP Maintenance Courses HIGH VOLTAGE COURSE Dynamic Positioning Induction Course Dynamic Positioning Simulator Course Dynamic Positioning Operators CERTIFICATE Dynamic Positioning Log book Details

ENTER DEPTTH IN METERS 25 MTR

Full or Limited

Section 10
SYSTEM DETAILS

Hours done with various DP system

Approx Hours as SDPO / Approx Days in case of Senior ETO / Senior Engineer Approx Hours as DPO / Approx Days in case of Junior ETO / Junior Engineer

APPROXIMATE Total DP Hours in Various Operations

SAT DIVING AIR DIVING ROV
WELL STIMULATION / INTERVENTION / ACTIVATION

CABLE LAYING SURVEY PIPE LAYING DRILL SHIP / SEMI SUB PSV SHUTTLE TANKER
ROCK DUMPING / MATTRESSING

AHTS FPSO CONSTRUCTION CORING HEAVY LIFT

TRENCHING
ACCOMMODATION / GANGWAY

Page 3 of 7 Section 11 Medical History

YES Have you ever signed off a ship due medical reason ? Have you undergone any medical operations in past ? Have you consulted a doctor during the past 12 months for an illness / Accident Do you have any health or disability problem now ?? If answer to any of above is YES then give further details below or on a separate sheet
WPIF M/01 12TH July 2011 Rev - 02

NO
NO NO NO NO

NOTE : All our clients have STRICT Alcohol and Drug Policy, Which means ZERO TOLERENCE for alcohol and drugs
Section 12 General
Yes
Have you ever been the subject of a court of enquiry or involved in a maritime accident Have you ever had a professional licence suspended or revoked Have you ever been convicted of any criminal offence? Have you ever been dismissed If yes to any of above then please full details below or on separate sheet of paper
NO NO NO NO

No

Section 13
Name of company

References

(Last Two Recent Employers)

SAMSON MARITIME MR ZAHIR MISTRY

Name Person to be contacted Address Tel No Email Name of company Name Person to be contacted Address Tel No Email 08866433039

SAMSON MARITIME LTD SITARAM MILL COMPOUND LOWERPAREL EAST MUMBAI 09819919925 Fax

CHITINAD MARITIME MR. K.K. MISHRA Fax SHASTRI NAGAR KALINA SANTACRUZ EAST MUMBAI

Section 14

Any other information, you wish to add in support of your application

Section 15

Declaration

I hereby declare that the above particulars are true and I authorize you to contact the referees listed above And confirm that All my certificates / Licences are Authentic / SEASERVICE RECORD is ACCURATE / And I confirm accepting Companies DRUG & ALCOHOL Policy

Signed LAXMI NARAYAN SHUKLA

Date 22.09.2011 Page 4 of 7

Rev - 02

WPIF M/01

12TH July 2011

Section 16 VESSEL

Record of Sea Service

Please give full record of sea service

(All Dates to be entered as dd/mm/yy)

STARTING FROM LAST VESSEL FIRST

Type of Engines Or DP System

COMPANY

Type of Vessel
And Type of operation in case of DP vessels

DWT or

GRT
(please delete as reqd)

BHP

RANK

Sign on DATE dd / mm / yy

Sign off DATE dd / mm / yy

06.06.2011 23.03.2011 05.09.2010 23.03.2010 18.09.2009 08.06.2009 09.03.2009 28.08.2008

M.V OCEAN TOPAZ MV OCEAN TOPAZ MV OCEAN TOPAZ MV AQUA MARINE MV PRIYANKA MV PRIYANKA MV FERRARI MV EAGLE

SAMSON MARITIME SAMSON MARITIME SAMSON MARITIME SAMSON MARITIME SAFE &SURE SAFE &SURE I-MARINE INFRATACH LILLY MARINE

TUG DIVING OPERATION TUG DIVING OPERATION TUG DIVING OPERATION TUG DIVING OPERATION M.B.C. M.B.C. TUG TUG

220 220 220 181 1441 1441 120 70

---------------

-----------------

CH/OFF CH/OFF CH/OFF CH/OFF 2ND OFF 2ND OFF TM-2 TM-2

24.042011 25.11.2010 17.07.2010 19.11.2009 03.08.2009 21.04.2009 07.12.2008 18.02.2008

WPIF M/01

12TH July 2011

Rev - 02

WPIF M/01

12TH July 2011

Rev - 02

Type of Engines :: for engineers only, DPOs to Mark DP System

BHP : for Engineers and AHTS / TUG Masters & Officers

Page 5 + 6 of 7

WPIF M/01

12TH July 2011

Rev - 02

ADDITIONAL INFORMATION SHEET VESSEL TYPE YOU ARE INTERESTED IN (please list in order of priority)
1 2. 3. 4. 5. TUG

MAXIMUM ACCEPTABLE CONTRACT PERIOD (Please indicate below)

04 MONTH

Please Quote Consolidated MINIMUM MONTHLY SALARY ( no leave pay ) payable for time onboard only or Working DAY RATE EXPECTATION ( no leave pay) ( please quote below in US$ -preferred or Euro or GBP ) US$ 2200/ Languages Spoken / Written / Understood (1-poor Spoken ENGLISH 5-Fluent) Written Understood

DRUG & ALCOHOL 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 reliefs Travel and recruiting costs, And Any other costs whatsoever incurred due to your NONCOMPLIANCE will be deducted from your salary, Which will include but not limited to damage to vessel her equipments and machineries, loss of charter, and any other costs Directly or indirectly connected with your NON-COMPLIANCE Sign & CONFIRM ACCEPTANCE OF ABOVE POLICY LNSHUKLA
FOLLOWING DOCUMENTS COPIES MUST BE SENT TO US- send to us In separate Email Licence or Certificate of competency, Any tanker endorsements, GMDSS showing expiry date in case of Deck Officers, Medical Fitness / Examination Certificate, Passport Main page, Seaman book or Discharge book Main pages, In case of DPO DPO Cert, DP LOG Pages
FOLLOWING ADDITIONAL DOCUMENTS will ALSO BE REQUIRED Send to us in separate email

All short courses certificates ( STCW95 ), SSO certificate, Last 3-5 years ships entries in Discharge book or Seaman book, Certificate of Equivelant Competency from other flag states

PAGE 7 of 7

WPIF M/01

12TH July 2011

Rev - 02