OPS/101

Rev. No. 5.0

01 Apr 2018
Page 1 of 4
REGI STERED OFFICE: UNIT NO. 52, 5TH FLOOR, KALPATARU SQUARE, KONDIVITA LANE, OFF. ANDHERI KURLA ROAD,
ANDHERI (EAST), MUMBAI 400 059 l TEL.: (022) 6150 7000 l FAX: (022) 6696 08 88 / 2825 4820
BRANCH OFFICE (Kolkata): BRANCH OFFICE (Chennai):
VASUNDHARABLDG., SPACE NO. 8, 5TH FLOOR, NO. 202, 2ND FLOOR, CAPITALTOWERS, 180
2/7, SARATBOSE ROAD, KOLKATA700 020 KODAMBAKKAM HIGH ROAD, NUNGAMBAKKAM, CHENNAI – 600034.
TEL: (033) 4003 3700/701/702/704 l FAX: (033) 4003 3715 TEL. : (044) 4292 9300 l Fax: (044) 4292 9301
BRANCH OFFICE (NewDelhi): 1301 – 1303, 13TH FLOOR, DEVI KATOWER, 6, NEHRU PLACE, NEW DELHI – 110 019.
Tel: 91-11- 41677766 / 4167 7788 / 011 2648 1127 l Fax: 91-11- 4167 7799

Em ail: apply @molm i.com l We bs ite : http://molmi.info/

How did you come to know about MOL / MOLMI ?

APPLICATION FORM PHOTOGRAPH

Dear Sirs,

I hereby apply for the post of and am ready to join from

I enclose herewith copies of all licenses, certificates and courses that I have completed.
Last name: First name: Other names:
Birth Date : Birth Place : Nationality:
Marital Status: Wedding Date:
Height: cm Weight : kg Collar: cm Chest: cm
Waist: cm Shoes: Eyes: Hair:
Colour Colour
Country Number Date Issued Valid till Place Issued
Passport
USA C1/D Visa
Seaman Book
Seaman Book
Have you ever been rejected for any visa applied for (YES/NO) :
Yellow Fever Vaccination (Date & Place) : (Lamination not accepted)

Permanent Address: Present Address:

Pin: Pin:
Tel/Mobile: Tel/Mobile:
E-Mail : Skype ID:
Ne xt of K in : (Plea se enter wi fe 's name i f marri ed)
Name : Relationship:
Address :
Pin:
Tel/Mobile: E-Mail :
Family Details:
Name Birth Date Birth Place P.P. No. Date Issued Place Issued Expiry
Wife:

Children: Sex
1

2
3

RECRUITMENT & PLACEMENT SERVICE LICENCE NO.: RPSL-MUM-064 VALID UNTIL18.12.2021

 OPS/101
Rev. No. 5.0
01 Apr 2018
Academic / Marine / Engineering Qualification and School / College attended : Page 2 of 4

Degree,
Name of School / College/ Date Attended Percentage of
Diploma or
Pre-Sea Training Institute/ Address Marks
Certificate
Engineering College Obtained
From To Received

Maritime Licences now Held:

Certificate of Competency Issuing Country Number Date passed Date issued Place Issued Valid Until
Master / Class I
Chief Mate / Class II
2nd Mate / Class IV
ETO / any other _______

List of STCW / Other Courses completed: INDoS No.:

Courses Certificate No. Date Issued Place Issued Expiry Date
PST (As per STCW 2010)
PSCRB (As per STCW 2010)
AFF / FPFF (As per STCW 2010)
MEDICARE / MFA / EFA (As per STCW 2010)
PSSR (As per STCW 2010)
SSO / STSDSD (As per STCW 2010)
REFRESH & UPDATING TRNG. (As per STCW 2010)

GMDSS - NATIONAL
ISSUED BY _________________ (COUNTRY)

GMDSS ENDORSEMENT (IF GMDSS IS INDIAN)

ECDIS GENERIC (Approved by National Administration)
ROC (As per STCW 95 / 2010)
ARPA (As per STCW 95 / 2010)
RANSCO / RADAR SIMULATOR
SHIP MANOEUVRING & BRIDGE TEAMWORK
HIGH VOLTAGE (Approved by National Administration)
HIGH VOLTAGE (LIMITATION DELETED)
SHIP HANDLING SIMULATOR
GAS TANKER FAM. / SAFETY (As per STCW 95 / 2010)
- DCE FOR GAS TANKER (As per STCW 95 / 2010)
WATCHKEEPING CERT. (DECK - II/4 / ENGINE - III/4)
COP - ABLE SEAFARER (DECK - II/5 / ENGINE - III/5)
COC AS COOK (MLC 2006)
SEAFARER PROFILE REGISTRATION

Previous company Contact Person: Tel.No.:

Have you experienced any major damage/grounding/court case ? Yes / No If yes, give details :

Did you suffer any accident which rendered you partially disabled? Yes / No If yes, give details :
 OPS/101
Rev. No. 5.0
Please start from last vessel first. 01 Apr 2018
Sea Service Record :
Please enter number of containers / cars loaded etc. in Vessel Particulars column Page 3 of 4
Vsl's Particulars S/On S/Off
No. of
Manning Owner Crew GRT BHP Date Date Remarks
Year cars/cont/HL Tonnage, Type Period
Type of Agent Operator etc
Name of Vessel Flag of Rank on
Vessel Nation- Type of M/E Make, A/E
Built DD-MMM-YY board Early S/off
Company Manager ality DWT KW Model, Cyl, Bore Dia, reason etc.
(Pls use "-" separator)
UMS/non-UMS

Office to verify vessel's particulars with CDC and Website.

Date : Place : Signature :

 OPS/101
Rev. No. 5.0
01 Apr 2018
FOR OFFICE USE ONLY : Page 4 of 4
GENERAL APPERANCE, PHYSICAL ATTRIBUTES, DRESS,
SENSE, MANNERS & ATTITUDE

EDUCATIONAL / PRE-SEA / NAUTICAL / MARINE

ENGINEERING BACK GROUND

PASSPORT ISSUANCE - PERSONAL IDENTITY

VERIFICATION

COMUNICATION SKILLS ACCORDING TO POSITION

(ENGLISH KNOWLEDGE)
EMPLOYMENT RECORD,
REASON FOR LEAVING PREVIOUS
EMPLOYER
SAFETY AWARENESS, KNOWLEDGE OF ISM CODE,
MARPOL, SOLAS, ENVIRONMENTAL PERCEPTION (ISO
14001-EMS, 50001-EnMS)

EXPERIENCE WITH OTHER NATIONALITIES CREW. CROSS

CULTURE KNOWLEDGE

EXPERIENCE WITH VARIOUS PORT STATE CONTROL,

FLAG STATE INSPECTION,RIGHTSHIP INSPECTION,
VETTING INSPECTION.

KNOWLEDGE OF TRADE IN SPECIAL AREAS LIKE WEST

AFRICA, INSPECTION BY PORT AUTHORITY, QUARANTINE
AUTHORITY ETC.

FULLY AUTOMATED ENGINE-ROOM EXPERIENCE

WITHOUT ELECTRICAL OFFICER'S SUPPORT

STEAM POWERED / OTHER SP. AUX. MACH. EXPERIENCE

LIKE BOW THRUSTER, SHAFT GENERATOR ETC.

DRY DOCK / NEW DELIVERY EXPERIENCE

TYPE OF PMS EXPERIENCE

HEALTH CONDITION CONFIRMATION

EXISTING ILLNESS, IF YES, MAINTAINANCE DRUGS

ALCOHOL/SMOKING/TOBACCO HABIT CONFIRMATION

Comments:

Date Name Signature MUM / KOL / CHN / DEL