Please Affix

Passport size
Photograph
Elegant Marine Services Private Limited
(Agents of Fleet Management Ltd.)
Our Principal’s Website: www.fleetship.com,
RPSL License No: MUM- 172
DOI: 18/09/2020 DOE: 18/09/2025

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: Local Address:

City: Tel.: City: Tel.:

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

Date of Issue Date of Expiry

Document No. Place of Issue
DD / MM/ YY DD / MM/ YY
Passport: Country
Seaman’s Book (CDC): National
Seaman’s Book (CDC): Norwegian
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 Visa 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 Details....................
Relationship First Name Last Name DOB Passport No. Place Issued Valid until
Spouse
Child M / F
Child M / F
* Indicate Type of Valid Visas USA / CANADA / BRAZIL / UK / Others
Anniversary date:
* Please check if visas a n d a l l d o c u m e n t s a r e v a l i d for the tenure on board, plus 6 months.

Page 1 of 11
FORM No.: Annex 11/OPM
REV. No.: 03 / 2020
Applicant Signature: _________________________

Page 2 of 11
FORM No.: Annex 11/OPM
REV. No.: 03 / 2020
(B) Education / Other Qualifications:
EDUCATIONAL QUALIFICATION
Result Grade (1st, 2nd,
10th Institution / University Year of Passing 3rd or A, B, C etc)
th Result Grade (1st, 2nd,
12 Degree Institution / University Year of Passing
PRE - SEA TRAINING / APPRENTICESHIP / MARINE ENGINEERING / NAUTICAL DEGREE OR DIPLOMA
Result Grade (1st, 2nd,
Pre - Sea T r ai ni ng T ra i n i n g I n sti t uti o n / Co m p an y Na m e From - To 3rd or A, B, C etc)

CERTIFICATES OF COMPETENCY:
Highest Competency Certificate Held
Date of Passing Examination
Issuing A u t h o r i t y Grade Certificate No. DOI Place Issued Valid unti l
National ( Country)
Liberian
Panamanian
Marshall I s l a n d
Norwegian
Hongkong
Others
GMDSS
GMDSS ( Endorsement)
LIST OF S.T.C.W. / OTHER COURSES DONE
Courses Certificate No.: STCW Certificate No.: Date of Issue Date of Expiry
1995 STCW 2010
1) FPFF / Advanced Fire Fighti ng
2) Elementary / Medical F i r s t A i d / Medicare
3) PSSR
4) Proficiency in Survival Craft & RB / PST
5) STSDSD
6) CTFC / CHEMCO
7) GTFC / GASCO
8) OTFC / TASCO
9) LCHS (Management / Operational)
10) Ship Maneuvering Simulator Course
11) Radar Observer Course / ARPA
12) Radar Simulator Course / RANSCO
13) BTM / BRM
14) Ship Security Officer Course
15) NIS Familiarization Course
16) C.O.C. Revalidation Course
17) INDOS No. (Mandatory Requirement)
18) STCW 2010 Refresher Courses
19) High Voltage Course
20) Seafarers Identify Documents (SID)
21) Others (Specify)
Dangerous Cargo Certification:
1. Endorsement on NATIONAL Certificate Level Number DOI Place Issued Valid Until
Petroleum
Liquefied Gas
Liquid Chemicals
2. Other Endorsements

Page 3 of 11
FORM No.: Annex 11/OPM
REV. No.: 03 / 2020
Applicant’s Signature

Page 4 of 11
FORM No.: Annex 11/OPM
REV. No.: 03 / 2020
(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

Remarks:

Sea Service with Fleet Management Vessels

Applicant’s Signature

FORM No.: Annex 11/OPM

REV. No.: 03 / 2020
(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 B r e a k d o w n e x p e r i e n c e / 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 S y s t e m
3 Carrier T r a n s i c o l d
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 / Maneuvering 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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REV. No.: 03 / 2020
 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

Applicant’s Signature

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REV. No.: 03 / 2020
(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 pressurized 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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REV. No.: 03 / 2020
 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

Applicant’s Signature

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REV. No.: 03 / 2020
 (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
(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 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 ____________________________________________________________________

(D) Last drawn salary in USD:

(E) 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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REV. No.: 03 / 2020
(H) FOR OFFICE USE ONLY

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

Documentation c h e c k s
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 : Marine / Tech. Superintendent / Manager / Deputy General Manager / General Manager) Name: Sign

Comments:

Regd. Office: Elegant Marine Services Private Limited: 401/A, Elegant Business Park, Off Andheri Kurla Road,
Near Kohinoor Continental Hotel, Andheri (E), Mumbai - 400 059. India
E-mail [email protected], Tel: (+91 22) 3090 6100 Fax: (+91 22) 3090 6200
e e

Liaison Offices: GURGAON: Tel. (0124) 4690400 / KOLKATA: Tel: (033) 40566100 /
KOCHI: Tel: (0484) 4063666 / CHENNAI: Tel. (044) 22504730 /
VIZAG: Tel (0891) 2749775 / PATNA: Tel. (0612) 2206788
LUCKNOW: Tel. (0522) 4024685 / CHANDIGARH: Tel. (0172) 4751200
JAIPUR : Tel (141) 4005091

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REV. No.: 03 / 2020