Read Naz Maritime Application Form - LATEST.xls text version

Samarpan Complex, CST 131 A 202 / 203, New Link Road, Chakala, Andheri (East), Mumbai 400099. Email: [email protected] / [email protected] Website: www.nazmarine.com Tel: 9833972723 / 9870002222 / 9821229593

Application Form

Application for Position As Availability date

NMS No.

Name First Name Nationality Date of Birth ddmmyy Place of Birth City Full Address Country INDOS No Sex Middle Name Age Surname

Country

Postal Code

Email ID

Home Telephone no.

Mobile Phone

Domestic Airport

International Airport

Marital Status:

Full name of Next of Kin / In case of Emergency or Accident

Relationship

Address

Home Telephone no. Dependents Name Date of Birth Age

Mobile Phone

Gender

Relationship

Percentage

Passport Number Place of Issue Date of Issue Date of Expiry Issuing Authority

WPIF ­ M /01

1ST FEB 2009

REV 0

Samarpan Complex, CST 131 A 202 / 203, New Link Road, Chakala, Andheri (East), Mumbai 400099. Email: [email protected] / [email protected] Website: www.nazmarine.com Tel: 9833972723 / 9870002222 / 9821229593

Application Form

Seaman's Book (CDC) Number

Place of Issue

Date of Issue

Date of Expiry

Issuing Authority

U.S. Visa Type Place of Issue Date of Issue Date of Expiry Remarks

Schengen Visa Type Place of Issue Date of Issue Date of Expiry Remarks

Yellow Fever Vaccination Date of Innoculation Date of Expiry

Certificate of Competency (COC) Grade

Number

Date of Issue

Date of Expiry

Place of Issue

Issuing Authority

Certificate of Endorsements (COE) Grade

Number

Date of Issue

Date of Expiry

Place of Issue

Issuing Authority

GMDSS Issuing Authority Number Date of Issue Date of Expiry Place of Issue

Dangerous Cargo Endorsements (DCE) Type of Endorsement Chemical Oil Gas Grade / Level Issuing Authority Number Date of Issue Date of Expiry

WPIF ­ M /01

1ST FEB 2009

REV 0

Samarpan Complex, CST 131 A 202 / 203, New Link Road, Chakala, Andheri (East), Mumbai 400099. Email: [email protected] / [email protected] Website: www.nazmarine.com Tel: 9833972723 / 9870002222 / 9821229593

Application Form

Details of STCW course and Other Marine courses Elementary First Aid Medical First Aid / Medicare Personal Survival Techniques Proficiency in Survival Craft & Rescue Boat Fire Prev. & Fire Fighting Advanced Fire Fighting Personal Safety and Social Responsibilities Oil Tanker Familiarisation Spec Training Prog on Oil Tanker Operation Liquified Gas Tanker Familiarisation Spec Training Prog on Liquified Gas Tanker Operation Chemical Tanker Familiarisation Spec Training Prog on Chemical Tanker Operation Revalidation Course Deck / Engine Refresher & Upgrading COCIPSCIFPFFIMFA Radar, Arpa and Navigation Simulator (RANSCO) Radar Observer Automatic Radar Plotting Aids Ship Security Officer Course ISPS Knowledge Liquid Cargo Handling Simulator Ship Manoeuvering Simulator Bridge Team Management (BTRM / BRM) Bridge Simulator Engine Room Simulator (BASIC / ADVANCED) ECDIS NABCO Hydraulic And Pneumatics Automation and Controls Reefer Container Maintenance PreSea Training for GP (Deck / Engine) / Saloon Watchkeeping (Deck / Engine) for Ratings Number Place of Issue Date of Issue Grade Issued By

WPIF ­ M /01

1ST FEB 2009

REV 0

Samarpan Complex, CST 131 A 202 / 203, New Link Road, Chakala, Andheri (East), Mumbai 400099. Email: [email protected] / [email protected] Website: www.nazmarine.com Tel: 9833972723 / 9870002222 / 9821229593

Application Form

Flag Endorsements for National Certificates Number Place of Issue Date of Issue Date of Expiry Issued By

Company

Name Of Vessel

From

To

TOTAL

RANK

Voyage Type (Foreign Going / Coastal)

Vessel Type

GRT

BHP

Main Engine

Medical History

YES NO

Have you ever signed off a ship due to medical reasons ? Have you undergone any medical operations in the past ? Have you consulted a Doctor during the past 12 months for 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

X X X X

WPIF ­ M /01

1ST FEB 2009

REV 0

Samarpan Complex, CST 131 A 202 / 203, New Link Road, Chakala, Andheri (East), Mumbai 400099. Email: [email protected]com / [email protected] Website: www.nazmarine.com Tel: 9833972723 / 9870002222 / 9821229593

Application Form

General YES Have you ever been the subject of a court for enquiry or involved in a maritime accident Have you ever had a professional license suspended or revoked If answer to any of above is YES then fill details below or on a separate sheet NO X X

Date When Promoted To Current Rank Last Wages Drawn Reason for Leaving Last Employer

Educational Background Name of School / College Attended City / Country From To Type of Degree/Diploma/Qualification Received

References Title Name Company Name Phone Number Address

Union Memberships Details Membership No. (For Officers) Seaman Registration no. (For Ratings) Additional Information Cargo's Carried Trading Pattern Nationalities Sailed With Miscellaneous Any other comments in support of your application Date

Date

WPIF ­ M /01

1ST FEB 2009

REV 0

Samarpan Complex, CST 131 A 202 / 203, New Link Road, Chakala, Andheri (East), Mumbai 400099. Email: [email protected] / [email protected] Website: www.nazmarine.com Tel: 9833972723 / 9870002222 / 9821229593

Application Form

Kindly let us know where did you find out about our recruitment Newspapers Internet Friends / Family members already in this organistion Others (Please specify)

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 relief's 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.

Declaration I certify that the details given by me in filling up this form are true, complete, and correct to the best of my knowledge and belief. I understand that any misrepresentation or material ommision made in this application form or other documents submitted to Naz Maritime Services may renders me liable for termination or dismissal. Date: Signature of the Applicant:

Place:

WPIF ­ M /01

1ST FEB 2009

REV 0

Information

Naz Maritime Application Form - LATEST.xls

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Naz Maritime Application Form - LATEST.xls