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APPLICATION FORM --- DETAILED PART - A : PERSONAL INFORMATION AND REFERENCE Rank Applied : DECK CADET First Name : PANKAJ Middle Name : Family Name : SHARMA Birth Date : 2/7/1987 Place Of Birth : UTTARKASHI,UTTRANCHAL Country Of Birth : INDIA Nationality : INDIAN Gender --- Male / Female : MALE Domestic IGIA Nearest Airport International IGIA Marital Status : SINGLE Available date of Joining : 1st Oct. Next Of Kin Name : MAHABIR SHARMA Next Of Kin - Relationship : FATHER G-2418,4th TYPE,NETAJI NAGAR NEW DELHI 110023 Next Of Kin - Address : Phone 011-26877927 Mobile Next Of Kin - Contact Details : E-mail gmahabir@gmail.com G-2418,4th TYPE,NETAJI NAGAR NEW DELHI 110023 Present Address : Contact Details : Permanent Address : Contact Details : Phone 011-26877927 Mobile E-mail sharma.sailor@gmail.com G-2418,4 TH TYPE,NETAJI NAGAR NEW DELHI 110023

Tel: 6500 4040Fax: 6500 4050

www.goodwoodship.com

Kindly paste a photograph : Size 50mm X 50mm

: Signature :

9013814211

9013814211

Phone 011-26877927 Mobile E-mail sharma.sailor@gmail.com : Family Particulars : Place Of Place Of Date Of Names Relationship Passport No. Birth Issue Birth MAHABIR SHARMAFATHER 10.06.57 HARYANA H3082282 DELHI PATASI DEVI MOTHER 07.02.62 HARYANA H3998612 DELHI PRIYA SHARMA SISTER 06.05.88 UTTARKASHI H1385400 DELHI

9968423670

Date Of ECNR Validity Expiry 01.02.2019 VALID 22.03.2019 VALID 03.11.2018 VALID

: Travel Documents : : Passport Details : : Seaman Book (CDC) Details : Number : F-4557840 Number : MUM145019 Place Of Issue : NEW DELHI Place Of Issue : MUMBAI Date Of Issue : 31.08.2005 Date Of Issue : 09.10.2007 Date Of Expiry : 30.08.2015 Date Of Expiry : 08.10.2017 Number : Visa Details Place Of Issue : U.S. Visa Singapore Visa Type C1/D Type Date Of Issue : Place Issued : NEW DELHI Place Issued : Date Of Expiry : Date Issued : 29.10.2007 Date Issued : Date Of Expiry : 25.10.2012 Date Of Expiry : : Mumbai Office : Goodwood Marine Services Pvt. Ltd. Valecha Chambers Ground Floor, New Link Road, Andheri (West), Mumbai 400 053, Maharashtra, India. Phone : + 91-22-4031 0404 Fax : + 91-22-4031 0405 E-mail :______________

LICENCES & DOCUMENTATION DETAILS C.O.C. -1 National C.O.C. - 2 C.O.C. - 3 Licence Grade : Licence Grade : Licence Grade : CLASS-3 Licence Number : Licence Number : Licence Number : D3-0004086 Date Of Issue : Date Of Issue : Date Of Issue : 09.09.2011 Date Of Expiry : Date Of Expiry : Date Of Expiry : 09.09.2016 Place Of Issue : Place Of Issue : Place Of Issue : SINGAPORE Country Of Issued : Country Of Issued : Country Of Issued : SINGAPORE MANDATORY & STCW COURSES DETAILS Date Of Date Of Names and Description Number Place Of Issue Issue Expiry Personal Survival Techniques 857 15.05.2007 IMI,GREATER NOIDA Profociency in Survival Craft P.S.C.R.B. 5.0035E+11 12.09.2008 TS RAHMAN,MUMBAI Fire Prevention & Fire-Fighting 998 18.05.2007 IMI,GREATER NOIDA Advanced Fire-Fighting 20330142008 06.09.2008 TS RAHMAN,MUMBAI Elementry First-Aid 995 15.05.2007 IMI,GREATER NOIDA Medical First-Aid 1.2036E+11 20.09.2008 TS RAHMAN,MUMBAI Ship Captain's Medicare Medical Care P. S. S. R. 939 17.05.2007 IMI,GREATER NOIDA Tanker familiarisation (Petroleum) 917 23.03.2007 IMI,GREATER NOIDA Tanker familiarisation (Chemical) 7211 30.11.2007 ARI,NEW DELHI Tanker familiarisation (Gas / LPG) 4594/201109.09.2011 MMTI,MUMBAI Specialised Tanker Safety (Pertoleum) TA11378 21/10/2011 ARI,NEW DELHI Specialised Tanker Safety (Chemical) SCT11315 7/10/2011 ARI,NEW DELHI Specialised Tanker Safety (Gas / LPG) Dangerous Cargo Endorsement (Petroleum) - Level 1 D/O/1/D/07/3087 03.12.2007 NEW DELHI,NOIDA Dangerous Cargo Endorsement (Chemical) - Level 1 D/C/1/D/07/3086 03.12.2007 NEW DELHI,NOIDA Dangerous Cargo Endorsement (Gas / LPG) - Level 1 Dangerous Cargo Endorsement (Petroleum) - Level 2 SINGAPORE Dangerous Cargo Endorsement (Chemical) - Level 2 D300004085 SINGAPORE Dangerous Cargo Endorsement (Gas / LPG) - Level 2 D300004086 SINGAPORE G.M.D.S.S. LICENCE WITH ENDORSEMENT GG038646 13.08.2010 UNITED KINGDOM Radar Observers course (ROC) Automatic Radar Plotting Aids (ARPA) Radar Simulator / ENS 044/2010 08.03.2010 SINGAPORE Engine Room Simulator Ship Handling Simulator Liquid Cargo Handling Simulator (2.5 Days) Liquid Cargo Handling Simulator (5.0 Days) E. C. D. I. S. ECDIS2011030 15/11/2011 19/11/2011 SEATRAIN Ship Manoeuring & Bridge Team Work BTM2011044 7/11/2011 9/11/2011 SEATRAIN Bridge Resource Management Ship Security Officer (S.S.O.) INDOS Number 07NL0587 07.06.2007 MUMBAI Yellow Fever Vaccination 03.11.2007 02.11.2017 NEW DELHI

: Mumbai Office : Goodwood Marine Services Pvt. Ltd. Valecha Chambers Ground Floor, New Link Road, Andheri (West), Mumbai 400 053, Maharashtra, India. Phone : + 91-22-4031 0404 Fax : + 91-22-4031 0405 E-mail :______________

NON-STCW & IN-HOUSE TRAINING / COURSES DETAILS Date Of Date Of Names and Description Number Issue Expiry Computer Evaluation System (CES) Testing HSQE Management System Familiarisation (MSF) Oil Pollution Act - 90 (OPA-90) with VRP Planned Maintenance System Familiarisatio (PMS) AMOS - D Familiarisation Personal Computer Familiarisation Bridge Team Training (BTT)
High Pressure HydraulicS Cargo Pump System (HPS / FRAMO)

Place Of Issue

Internal Auditor's Course Energy Conservation Course Risk Accessment / Management Course Accident Investigation / Prevention Course Human Behavior & Relationship Course On Board Commercial Management Course Inspection / Surveys / Vetting Familiarisation ISPS Familiarisation Course Vessel Resource Management Course Engine Room Team Manegement Course Onboard Safety Officer / MARPOL Couse Commercial Awareness Course Training Of Trainers Course HAZMAT Course MARLIN'S English test

Curriculum Primary School

Name Of School / College

Educational Background & Training City / Type Of Qualification -- Diploma / Degree / From To Country Certificates Received

Secondary School Pre-Sea Training Nav. College - 1 Nav. College - 2 Nav. College - 3

IMI,GREATE R NOIDA INDIA

01.08.2005 30.04.2007 HIGHER NATIONAL DIPLOMA in NAUTICAL SCIE

Any Remarks :

: Mumbai Office : Goodwood Marine Services Pvt. Ltd. Valecha Chambers Ground Floor, New Link Road, Andheri (West), Mumbai 400 053, Maharashtra, India. Phone : + 91-22-4031 0404 Fax : + 91-22-4031 0405 E-mail :______________

D/
Type (OBO / VLCC / Tanker / Chemical / Gas Etc.)

Sr.

Vessel Name

Flag

DWT

Engine Type

BHP

Manning Agents / Owners Name

Rank

From

To

M o n t h s

D a y s

1 NORDIC COPENHAGEN SINGAPORE CHEMICAL 12448 FIXED PITCH 46060 EMS STROKE DECK CADET 24.12.2007 25.08.2008 8 1 2 SAMCO ASIA VLCC MARSHALL ISLANDS PITCH 4 STROKE 330000 FIXED GOODWOOD DECK CADET 02.12.2008 07.05.2009 5 5 3 MATILDA OBO LIBERIA 70000 FIXED PITCH 49378 GOODWOOD STROKE DECK CADET 18.07.2009 18.12.2009 5 1 4 5 6 7 8 9 10 11 12 13 14 15 16 ACTUAL TIME SERVED IN MONTHS TANKERS Contain General Bulk RANK VLCC OBO Ro Ro Others Crude Product Chemical LPG LNG er Cargo Carrier M D M D M D M D M D M D M D M D M D M D M D M D Master Chief Officer Second Officer Third Officer Deck Cadet 8 1 Chief Engineer Second Engineer Third Engineer Fourth Engineer Jr. Eng. / Eng Cdt El. Officer Other Rank : DURING YOUR TENURE ON VARIOUS TYPE OF TANKERS, KINDLY LIST THE TYPE OF CARGOES CARRIED :

: Mumbai Office : Goodwood Marine Services Pvt. Ltd. Valecha Chambers Ground Floor, New Link Road, Andheri (West), Mumbai 400 053, Maharashtra, India. Phone : + 91-22-4031 0404 Fax : + 91-22-4031 0405 E-mail :______________

REFERENCES & MISCELLANEOUS INFORMATION PRESENT OR LAST COMPANY (1) PRESENT OR LAST COMPANY (2) Name Of Company Name Of Company Address Of Company Telephone Number Person to Contact Designation / Position Reason for Leaving Address Of Company Telephone Number Person to Contact Designation / Position Reason for Leaving PHYSICAL / HEALTH DECLARATION 168 Weight (Kgs) BLACK Eyes Colour BLACK BLACK MARK ON THE RIGHT SIDE OF NOSE Yes No Condition NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Rheumatic Or Joint Trouble Chronic Back Pain OR Back Problem Sleep Problem Any Operation / Surgery Epilepsy / Seizures Dizzyness / Fainting Loss Of Consciousness Mental Disorder Depression Attempted Sucide Loss Of Memory Balance Problem Severe Headaches Ear / Nose / Throat Problems Restricted Mobility Back Problems Amputation Fractures / Dislocation

Height (Cms) Hair Colour Identification Mark On Body (If Any) Condition Eye / Vision Problem High Blood Pressure Heart / Vascular Disease Heart Surgery Varicos Vains Asthama / Bronchitis Tuberculosis / Other Lung Disease Blood Disorder Diabetes Mellitus Thyroid Problem Digestive Disorder Kidney / Bladder Problem Skin Problem Allergies Infactious / Contagious Disease Hernia Genital Disorders Cancer / Or Tumor

65

Yes

No NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

If any of the above questions were answered "YES", Then please provide details :

: Mumbai Office : Goodwood Marine Services Pvt. Ltd. Valecha Chambers Ground Floor, New Link Road, Andheri (West), Mumbai 400 053, Maharashtra, India. Phone : + 91-22-4031 0404 Fax : + 91-22-4031 0405 E-mail :______________

: ADDITIONAL QUESTIONS ON HEALTH : Have you ever been signed-off as sick or repatriated from a vessel ?. Have you ever been hospitalised ?. Have you ever been declared unfit for sea-service duty ?. Has your medical certificate ever been restricted or revoked ?. Are you aware that you have any medical problems, diseases or illness ?. N Are there any aspects of your health which may affect your on board work ? Do you feel healthy and fit to perform the duties of your designated position / occupation ? Have you had a problem with drug or alchohol abuse ? Do you have any injury or injuries causing persistent incapacity, pain or trouble ? Are you allergic to any medication or particular item ? Are you taking any non-prescribed or prescribed medication ? If any of the above questions were answered "YES", Then please provide details : NO NO NO NO NO NO NO NO NO NO NO

BANKING & OTHER REQUIRED DETAILS Banificiary Account Number Name Of Bank Bank Address Mailing Address (Home / Bank) ANY PREVIOUS SHORE EXPERIENCE

I HEREBY CERTIFY / DECLARE THAT THE ABOVE DETAILS ARE CORRECT TO THE BEST OF MY KNOWLEDGE.

signature of applicant

Date

: Mumbai Office : Goodwood Marine Services Pvt. Ltd. Valecha Chambers Ground Floor, New Link Road, Andheri (West), Mumbai 400 053, Maharashtra, India. Phone : + 91-22-4031 0404 Fax : + 91-22-4031 0405 E-mail :______________

OFFICE USE ONLY

English Proficiency Competence (CES Test) Has the candidate's COC is varified from issuance authorities Interviewed By Designation Date of Interview Suitable for Employment YES NO : COMPETENCE EVALUATION OF SEAFARER : Exceeds Meets Below Exceeds YES Meets NO : INTERVIEW SELECTION : Below

: REFERENCE CHECK FROM PRESENT OR PREVIOUS EMPLOYER : Reference Check Made By : Date of Reference Check : Name Of Person giving reference : Position / Designation : RECOMMENDED FOR EMPLOYMENT

Particulars

Excellent

Above Average

Average

Below Average

Ability Health / Medical Condition Personal Conduct Any Alchohol / Drug Problem Persormance Recommended for Re-Employment Interpersonal Relations Attitude Towards Work Teamwork / Leadership Qualities Is The Qualification in Compliance

YES

N O

Name Of Interviewer

Signature Of Interviewer

DATE

: Mumbai Office : Goodwood Marine Services Pvt. Ltd. Valecha Chambers Ground Floor, New Link Road, Andheri (West), Mumbai 400 053, Maharashtra, India. Phone : + 91-22-4031 0404 Fax : + 91-22-4031 0405 E-mail :______________

: Mumbai Office : Goodwood Marine Services Pvt. Ltd. Valecha Chambers Ground Floor, New Link Road, Andheri (West), Mumbai 400 053, Maharashtra, India. Phone : + 91-22-4031 0404 Fax : + 91-22-4031 0405 E-mail :______________