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Elegant Marine Services Private Limited (LIC No. RPSL-Mum-172)

(Agents of Fleet Management Ltd.)
Our Principal’s Website : www.fleetship.com
Application Form / Personnel Data Update Form
Post applied for : Willing to accept lower rank ? Yes No Available From : / /

(A) PERSONAL PARTICULARS (AS IN PASSPORT)

First Name Middle Name Last Name/Surname

Nationality Date of Birth Place of Birth

Height Weight (In KGS) Smoker / Nonsmoker Yellow Fever Union Membership
(In CMS) Blood Group Veg. / Non - Veg. DOI DOE BATCH /LOT No.
YES NO
Boiler Suit Size : MED / LARGE / XL / XXL Shoe Size :

Permanent Address : Present Address :

City : Tel. : City : Tel. :

Post Code : Mobile : Post Code : Mobile :
E-mail : Nearest Airport :

Document No. Date of Issue Place of Issue Date of Expiry

DD/ MM / YY DD/ MM/ YY
Passport : Country
Seaman’s Book (CDC) : National
Seaman’s Book (CDC) : Liberian
Seaman’s Book (CDC) : Panamanian
Seaman’s Book (CDC) : Marshall Island
Other (CDC) :

Valid US Visa “C1/D” Yes / No Date of Expiry : Passport ECNR : Yes / No

Australian Maritime Crew Visa Yes / No Date of Expiry :

Next of kin : Relationship : DOB :

Alternate next of kin :
(in case of family joining) Relationship :

Address :
Tel. :
....................Family Data....................
Relationship First Name Last Name DOB Passport No. Place Issued Valid until
Spouse
Child M / F
Child M / F
Indicate Type of Valid Visa : USA CANADA BRAZIL UK OTHERS
*
Anniversary Date :

* Please check if visa and all documents are valid for the tenure on board, plus 6 months.
FORM NO : EMSPL / 02 / 2013
REV. NO : 02 / 2016
Applicant’s Signature
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(B) Education / Other Qualifications :
EDUCATIONAL QUALIFICATION
Result Grade (1st, 2nd,
10 + 2 / Degree Institution / University Year of Passing 3rd or A, B, C etc)

PRE - SEA TRAINING / APPRENTICESHIP / MARINE ENGINEERING / NAUTICAL DEGREE OR DIPLOMA

Result Grade (1st, 2nd,
Pre - Sea Training Training Institution / Company Name From - To 3rd or A, B, C etc)

CERTIFICATES OF COMPETENCY :
Highest Competency Certificate Held
Date of Passing Examination
Issuing Authority Grade Certificate No. DOI Place Issued Valid until
National (Country)
Panamanian
Marshall Island
Hongkong
Others
GMDSS
GMDSS (Endorsement)
LIST OF S.T.C.W. 1995/2010 OTHER COURSES DONE
Courses Cert. No. 95 Cert. No. 2010 Date of Issue Date of Expiry
1) FPFF / Advanced Fire Fighting
2) Proficiency in Survival Craft & RB / PST
3) Elementary / Medical First Aid / Medicare
4) PSSR
5) CTFC / CHEMCO
6) OTFC / TASCO
7) GTFC / GASCO
8) LCHS : (Management / Operational)
9) Ship Manouvering Simulator Course
10) Radar Observer Course / ARPA
11) Radar Simulator Course / RANSCO
12) BTM / BRM
13) ISPS (SSO / STSDSD) Course
14) NIS Familiarisation Course
15) C.O.C. Revalidation Course
16) INDOS NO (Mandatory Requirement)
17) ECDIS General / Type Specific
18) STCW 2010 Refresher Courses

19) Others (Specify)

Dangerous Cargo Certification :
1. Endorsement on NATIONAL Certificate Level Number DOI Place Issued Valid Until
Petroleum
Liquified Gas
Liquid Chemicals
2. Other Endorsements

Applicant’s Signature [ 2 / 10 ]
 (C) SEA SERVICE : (Start From Last Vessel Served)
Flag of Type of Engine make & model & BHP/KW (For Engineers) DWT (D) From To Total
Name of the Company Name of the Vessel Rank
Vessel Vessel Cargoes Carried (For Deck Officers) GRT (G) dd/mm/yy dd/mm/yy M/D
Non Fleet Management Vessels
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Remarks :

Sea Service with Fleet Management Vessels

Applicant’s Signature
(D) Experience Matrix of Engineer Officer
Please mark ‘Y’ against your rank in the cell, if that experience is applicable to you
S.No. Crane Make C/E 2/E 3/E 4/E E/O Any Breakdown experience / Remarks
Experience on Deck / Cargo Machinery
1 Haaglund
2 Liebherr
3 IHI
4 Mitsubishi
5 NMF
6 Atlas
7 BLM
8 MacGregor
9 Any Other
Grab Make
1 SMAG Peiner
2 ORTS
Experience on Reefer Machinery / Reefer Container
1 Direct System
2 Indirect System
3 Carrier Transicold
4 Thermoking
5 Daikin
6 Mistubishi
7 Any Other
Experience on Oil / Chemical / Gas Tankers
1 Framo Pumps
2 Centrilina Pumps
3 Steam Turbines
4 Any Other
Experience on Propulsion System / Manoeuvering System
1 CPP
2 Bow/Stern thruster
3 Twin Screw
4 NOR Control
5 Kongsberg
6 Any Other
Experience on Auxilliary Engines
1 Yanmar
2 Daihatsu
3 Sulzer
4 MAN B&W
5 Cummins
6 Caterpillar
7 Pielstik
8 Volvo Penta
9 Any Other

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 S.No. Crane Make C/E 2/E 3/E 4/E E/O Any Breakdown experience / Remarks
Experience of major overhaul / breakdown
1 Drydock
2 M/E Turbocharger
3 M/E Governer
4 M/E Cyl. Liner
5 Thrust Block
6 A/E Crankshaft
7 Alternator overhaul
8 Steering Gear
9 Any Other
Experience in Disaster Management
1 Grounding
2 Collision
3 Oil Spill
4 Crank Case Explosion
5 Scavenge Fire
6 Engine Room Fire
7 Cargo Fire
8 Abandon Ship
9 Steering Failure
10 Any Other
Experience in PMS
1 AMOS
2 TM Master
Additional Comments to Explain above

Applicant’s Signature

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(E) Experience Matrix of Deck Officer
Please mark ‘Y’ against your rank in the cell, if that experience is applicable to you
S.No. Description M CO 2O 3O Cdt Any Breakdown or incident experience / Remarks

Have you sailed in the following areas ?

1 Indian Ocean
2 Pacific Ocean
3 North Atlantic Ocean
4 South Atlantic Ocean
5 South China Sea
6 Australian Waters
7 Mediterranean Sea
8 Black Sea
9 English Channel / North Sea
10 Singapore Straits
11 Panama Canal
12 Suez Canal
13 Kiel Canal
14 Great Lakes
15
16
17
Chemical / Product Tanker Tank Cleaning experience
1 Cleaned tanks after carriage of veg. oil ?
2 Cleaned tanks for Methanol carriage ?
3 Cleaned tanks MEG or similar cargoes ?
4 Cleaned tanks for Veg Oil carriage ?
5 Cleaned tanks for Jet Fuel ?
6 Changed from dirty to clean products ?

Gas Tanker Experience

1 Fully Refrigerated vessel
2 Fully pressurised vessel
3 Partially refrigerated vessel

Oil / Product / Chemical Tanker Experience

1 Inert Gas vessel
2 Crude Oil Washing
3 Inert Gas purging
4 Cleaning crude oil tanks for hot work
5 Framo Pumps operation
6 Cargo Heating
7 Framo Pump damage
8 Over / Under pressurization of tanks
9 Cargo contamination

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 S.No. Description M CO 2O 3O Cdt Any Breakdown or incident experience/ Remarks

Bulk Carrier Experience

1 Hose test for hatch covers
2 Bilge valve testing
3 Ballasting of cargo hold
4 Disposal of cargo residues
5 Draft survey cargo calculations
6 Over / Under pressurization of Holds
7 Cleaned Holds for Grain carriage ?
8 Cleaned Holds for Fertilizer carriage ?

Experience of major overhaul / breakdown

1 Drydock
2 Windlass damage / Loss of Anchor
3 Sterring Gear failure

Experience of Special circumstances & Disaster Management

1 Grounding
2 Collision
3 Oil Spill
4 Crank Case Explosion
5 Scavenge Fire
6 Engine Room Fire
7 Cargo Fire
8 Abandon Ship
9 Steering Failure
10 Freezing Weather
11 Heavy weather / TRS
12 Fog / Restricted visibility

Experience in PMS
1 AMOS
2 TM Master
Additional Comments to Explain above

Applicant’s Signature

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(F) GENERAL :
(1) Have you ever been denied a foreign visa or been deported from any country ? Yes / No
If yes, state which country and reason (if known) :
(2) Have you been the subject of a court of enquiry or involved in a maritime accident ? Yes / No
If yes, please attach details
(Collision, Grounding, Fire, Pollution)
(3) Have you ever signed off a ship due to medical reason within last 3 years ? Yes / No
If yes, please provide following details :
Name of vessel Date of occurrence Illness Place of occurrence

Reason for sign off :

(4) Have you ever been involved in any criminal activity or have pending criminal case ? Yes / No
If yes, please provide details
______________________________________________________________________________________________
______________________________________________________________________________________________
(5) Have you ever been involved in any navigational incidents in last 24 months ? Yes / No
If yes, please provide details

______________________________________________________________________________________________
(6) Are you currently under medical treatment or taking medication for existing conditions ? Yes / No
If yes, please provide details
Comments on above ____________________________________________________________________________
______________________________________________________________________________________________
(7) Last drawn salary in USD :
Please provide copy of your Account of wages.
(8) References
Please give referees from two recent employers who we may contact for references
Reference 1 Reference 2
Name of Company
Name of Person to contact
Address

Country
Telephone
I Do hereby declare that all information furnished is true to best of my knowledge and belief.

Received acknowledgement of Application form

Date : Rank : Applicant’s Signature

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(G) FOR OFFICE USE ONLY

Elegant Marine Services Private Limited. (LIC No. RPSL-Mum-172)

(Agents of Fleet Management Ltd.)
Our Principal’s Website : www.fleetship.com

SHIP’S STAFF INTERVIEW FORM

STAGE I

Name of Candidate : Date :

Rank Applied For : Location of Interview :

Interview Method (Physical / Telephone / Video Conference) :

This form shall be used to document the observations made during the interview. The interviewer may provide
his recommendations for additional training if required.

For items marked ‘Poor’. Please give your comments.

A. Appearance / Character V.GOOD GOOD S’FACTORY POOR N/A

1 Dress
2 Grooming
3 Body language
4 Communication skills

Comments if any :

B. Professional knowledge V.GOOD GOOD S’FACTORY POOR N/A

1. Navigation and Watch keeping

2. Cargo work
3. Technical Knowledge
4. Safety awareness
5. Engineering Knowledge
6. Awareness of regulations

Comments if any : (

Result of Interview : Suitable / Not suitable for employment

Suitable For Vessel Type : Rank :

Interviewed By Name Signature

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(H) FOR OFFICE USE ONLY

STAGE II (Checked by : Personnel Officer) Name : Sign

Documentation checks
a) Copies of all STCW certificates received ? Yes / No
b) Copy of all valid Certificates of Competency including Endorsements received ? Yes / No
c) Copy of National or Main Certificate of Competency verification certificate received ? Yes / No
d) Copies of Passport including all valid visas received ? Yes / No
e) Copies of Seaman’s Book including all pages containing sea service received ? Yes / No
f) Copies of Vaccination Book received ? Yes / No
Comments regarding non-receipts :

STAGE III (Assessed By : Superintendent / Manager / Sr. Manager / D.G.M. / G.M.)

Name : Sign

Comments :

Regd. Office : Elegant Marine Services Private Limited :602, The Great Eastern Galleria, Sector-4, Nerul, Navi Mumbai- 400 706
CorporateOffice : Elegant Marine Services Private Limited : 601/A, Elegant Business Park, Off Andheri Kurla Road,
Near Kohinoor Continental Hotel, Andheri (E), Mumbai - 400 059. India
Tel. : (+91 22) 3090 6100 z Fax : (+91 22) 3090 6200 z E-mail : seacareer@elegantship.com
Branch Offices : DELHI : Tel. (0124) 469 0400 z KOLKATA : Tel. (033) 4006 1030 Fax (033) 4006 1039
KOCHI : Tel. (0484) 406 3666 Fax (0484) 406 3665 z CHENNAI : Tel. (044) 2431 4744 Fax (044) 2431 4746
VIZAG : Tel. (0891) 274 9775 Fax (0891) 271 9775 z PATNA : Tel. (0612) 220 6788 Fax (0612) 220 6792
LUCKNOW : Tel. (0522) 402 4685, 402 4686, 407 6494 z CHANDIGARH : Tel. (0172) 464 7015

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