MILAHA SHIP MANAGEMENT

APPLICATION FORM MSM – OOV – SM - 151

Rank Applied SECOND OFICER DPO LOWER POSITION ACCEPTED NO

DATE APPLIED 29.10.2018 DATE OF AVAILABILITY 02.11.2018

1. PERSONAL DETAILS
1. SURNAME FIRST NAME
MIDDLE NAME

NAME SHARMA SAURABH

Place of Nationali PHOTOGRAPH
Date of Birth 11.02.1979 KOCHI, KERELA INDIAN
Birth ty
Permanent Address : D/3204, LLOYDS ESTATE ,
Present Address : SAME AS PERMANENT
NEAR VIT COLLEGE , WADALA EAST, MUMBAI -
ADDRESS
400037
City & Pin code: MUMBAI , 400037 City & Pin code: MUMBAI , 400037
Mob Teleph
Telephone 91-22-24161888 +919920460728 +919930360728
ile one
E-mail
Email 1 [email protected] [email protected]
2
Next of
Relation Telepho
Kin POONAM SHARMA WIFE +919619971442
ship ne
(Name)
Address of next of kin: D/3204, LLOYDS ESTATE, NEAR VIT COLLEGE, WADALA EAST , MUMBAI -
400037
Nearest International Airport : MUMBAI CST
Languag ENGLISH,
Blood
Height 5’10” Weight 92 kgs es HINDI,
Group
Known PUNJABI
Numbe
Marital MARR 2X Sh Name of r of
Cover All 8 POONAM SHARMA 01
Status IED L oe Spouse Childre
n
2. TRAVEL DOCUMENT DETAILS
Number Place of Issue Date of Issue Date of Expiry

PASSPORT Z2471812 MUMBAI 03.12.2012 02.12.2022

SEAMAN BOOK MUM 105339 MUMBAI 19.10.2012 18.10.2022
3. ACADEMIC QUALIFICATIONS Grade / Degree From (Year) To (Year)

School / College 10+2 10+2 1998

1997
Pre-sea Training T.S. RAHAMAN
PRE SEA 1998 1998
Institute
4. LICENCE / CERTIFICATE OF COMPETENCY
Issuing Date
Capacity Any Limitations Number Date of Issue Date of Expiry
Authority Revalidation
National CHIEF MATE NONE
Certificate D2-0005840 26.10.2016 26.10.2021
F.G.,UNLIMITED
Endorsement of SSINSINGPORE
National
Certificate

Rev 00 Date: 01-Apr-2018 Page 1 of 7

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 MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151

Qatar
Endorsement
5. STCW AND OTHER CERTIFICATES
STCW COURSES Certificate No. Date of Issue Date of Expiry Place of Issue Issuing Authority /INSTITUTE
GMDSS/GOC GOC 6688 17.04.2016 16.04.2021 NEW DELHI WPC, NEW DELHI

WATCHKEEPING CERTIFICATE FOR

RATING

ELECTRO TECHINAL RATING

PERSINAL SAFETY AND SOCIAL 5F0F41F1B7C MUMBAI
RESPONSIBILITIES (PSSR) 19.03.2016 N.A. NAMAC , MUMBAI
ED705
BASIC SEA SURVIVAL / TRAINING MUMBAI
016371 08.08.1997 N.A. T.S. RAHMAN
PERSONAL SURVIVAL TECHNIQUES MUMBAI
(PST) BPMA/PSCRB-
21.09.2015 20.09.2020 BP MARINE, SINGAPORE
RF/3963/2015
Fire protection & Fire fighting
(FPFF) / elementary First Aid (EFA)
ADVANCED FIRE FIGHTING (AFF) MUMBAI
15156000681
14.09.2015 13.09.2020 MTI, MUMBAI
177
MFAC/ MUMBAI
MEDICAL FIRST AID 03.05.2001 N.A. NAMAC, MUMBAI
0199/017/200
1
MMC/ MUMBAI
MEDICARE ONBOARD SHIP 07.09.2015 06.09.2020 NAMAC, MUMBAI
0071/007/10
PROFICIENCY IN SURVIVAL CRAFT &
RESCUE BOATS (PSCRB) SAME AS PST
PROFICIENCY IN SURVIVAL CRAFT
SAME AS PST

ROC
990805 21.10.1999 N.A. MUMBAI LBS , MUMBAI

ARPA
ARPA/991074 05.11.1999 N.A. MUMBAI LBS, MUMBAI
SIMULATOR TRAINING

RANSCO / RSC 120096 05.10.2012 N.A. MUMBAI LBS, MUMBAI

SMS / NAV CONTROL 1610551 11.10.2016 N.A. SINGAPORE SMA, SINGAPORE

ENGINE SIMULATOR

MRM-112-02- ALL, ANGLO EASTERN ,

BTM / ETM 07.04.2016 N.A. MUMBAI
3590 MUMBAI

OTHER COURSES
ILO - MEDICAL FITNESS CERTIFICATE

YELLOW FEVER
AIRPORT HEALTH
8274 21.02.2018 N.A. MUMBAI
ORG.MUMBAI
SIMS/LNV/
FAST RESUCE CRAFT (FRC) 30.11.2016 LONAVLA SIMS, LONAVLA
FRB/
04/2016/09
00649014201
H2S/BOSIET 20.12.2016 19.12.2018 MALAYSIA MSTS, MALAYSIA
216609133

MARLINS ENGLISH TEST

64765700191 SURAKSHA MARINE,
HUET 19.11.2016 18.11.2020 THANE
116335 THANE

Rev 00 Date: 01-Apr-2018 Page 2 of 7

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MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151

MMTI/SSO/
SHIP SECURITY OFFICER (SSO) 24.01.2014 N.A. MUMBAI MMTI, MUMBAI
302/2014

SECURITY FAMILARISATION
SECURITY DESIGNATED DUITES

CRANE OPERATOR

RIGGER / SLINGER
DP CERTIFICATES

DP MAINTENANCE COURSE

INDUCTION

SIMULATOR

DP OPERATOR’S LICENSE 31451 21.08.2017 21.08.2022 Full / Limited FULL

Total DP Hrs in 389 HOURS AS Total DP hrs as Junior 2800 HOURS AS
DP LOG BOOK DETAILS
Present Position SECOND OFFICER Position SECOND MATE JDPO
DPO
HOURS DONE WITH VARIOUS DP SYSTEM
SYSTEM DETAILS Hours as SDPO Hours as JDPO
BRIDGEMATE (MT) 450
KONGSBERG, KPOS DP-21 1200
KONGSBERG, KPOS DP-22 389 HOURS AS DPO 1150
APPROXIMATE TOTAL DP HOURS IN VARIOUS OPERATIONS

DSV/ROV

389 2800
AHTS/PSV

ANY OTHER INFORMATION

6. MEDICAL HISTORY
YES NO
Have you ever signed off a ship due medical reason? X
Have you undergone any medical operations in past? X
Have you consulted a doctor during the past 12 months for an illness/Accident? X
Do you have any health or disability problem now? X
If answer to any of above is YES then give further details below or on a separate sheet

NOTE: All our clients have STRICT Alcohol and Drug Policy, which means ZERO
TOLERANCE for alcohol and drugs

7. GENERAL
YES NO
Have you ever been the subject of a court of enquiry or involved in a maritime accident? X
Have you ever had a professional license suspended or revoked? X
If yes to any of above then please fill details below or on separate sheet of paper

Rev 00 Date: 01-Apr-2018 Page 3 of 7

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MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151

8. REFERENCES (LAST EMPLOYER)

NAME OF COMPANY MORIAH MARINE SERVICES PVT. LTD.
Name of person to be Contacted SWAPNIL
Address
Telephone: Mobile:+65 9653 9733 Fax:
Email: Last Salary Drawn USD 250/DAY
Reason for leaving: LONG LEAVE TO REJOIN VESSEL

ANY OTHER INFORMATION, YOU WISH TO ADD IN SUPPORT OF YOUR APPLICATION

9. DECALARATION
I hereby declare that the above particulars are true and I authorize you to contact the referees listed above
and certify that the details given by me in filling up this form are true, complete, and correct to best of my
knowledge and belief. I understand that any misrepresentation or material omission made in this
application form or other documents submitted to MSM may renders me liable for termination or
dismissal.

Date: ___29.10.2018____ SIGNATURE OF APPLICANT___________________

Rev 00 Date: 01-Apr-2018 Page 4 of 7

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MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151

10. ADDITIONAL INFORMATION SHEET

Languages Spoken/Written/Understood (1-poor 5-Fluent)
LANGUAGES SPOKEN WRITTEN UNDERSTOOD
ENGLISH 5 5 5
HINDI 5 5 5

DRUG & ALOCOHOL 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 NON-COMPLIANCE will be deducted from
your salary, which will include but not limited to “damage to vessel her equipment’s and machineries,
loss of charter, and other costs Directly or indirectly connected with your NON-COMPLIANCE

SIGN & CONFIRM ACCEPTANCE OF ABOVE POLICY…………………………………………

FOLLOWING DOCUMENTS COPIES MUST BE SENT TO US – send to us in separate Email

Certificate of Competency and Endorsement certificates, GMDSS/GOC certificate showing expiry date in
case of Deck Officers, DP Certificate, DP log book details, Medical Certificate, Passport and Seaman Book
FOLLOWING ADDIDITIONAL DOCUMENTS WILL ALSO BE REQUIRED
Medicare certificate, STCW 2010 endorsement certificate, ISPS Code Certificates, Ship Security Officer
(SSO) certificate. Marlin English test, Crane Operator certificate, Fast Rescue Crafts Certificate, last 3-5
years ships entries pages in Discharge book or seamen book.

Rev 00 Date: 01-Apr-2018 Page 5 of 7

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MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151
11. S E A E X P E R I E N C E : (Most recent first)
COMPANY / VESSEL PERIOD MAIN ENGINE REASON FOR
AGENTS NAME TYPE GRT DP System DP hrs RANK FROM TO M/D MAKE MODEL BHP SIGN-OFF
MORIAH MARINE AHTS OSHE REWO AHTS 2623 KPOS DP NONE CHIEF 05.08.2018 19.08.2018 0 / 15 6000 CONTRACT
SERVICES PTE. 22 OFFICER COMPLETION (IT
LTD. WAS ONLY 20
DAYS CONTRACT)
MORIAH MARINE AHTS OSHE REWO AHTS 2623 KPOS DP 10 CHIEF 22.03.2018 16.06.2018 02 / 6000 CONTRACT
SERVICES PTE. 22 OFFICER 25 COMPLETION
LTD. (WAS INVOLVED
IN DP & SEA
TRILAS)
ESM OFFSHORE EXECUTIVE PSV 3383 KPOS DP 389 SECOND 13.09.2017 14.12.2017 03/02 6330 COMPLETION OF
COURAGE 22 MATE
CONTRACT( SHELL
DPO
CHARTER)
ESM OFFSHORE EXECUTIVE PSV 3383 KPOS DP 610 SECOND 25.05.2017 27.07.2017 02/03 6330 COMPLETION OF
COURAGE 22 MATE
CONTRACT(SHELL
JDPO
CHARTER)
ESM OFFSHORE EXECUTIVE VALOUR PSV 3383 KPOS DP 815 SECOND 04.01.2017 17.04.2017 03 / 6330 COMPLETION OF
22 MATE 15
CONTRACT(SHELL
JDPO
CHARTER)
CS OFFSHORE MDPL ANJALI MPSV 3542 KPOS DP 975 SECOND 04.05.2015 27.07.2015 02 / 5915 COMPLETION OF
21 MATE 24
CONTRACT(TOTAL
JDPO
CHARTER)
CS OFFSHORE MDPL CONQUEROR AHTS 2558 BRIDGE 95 SECOND 21.02.2015 20.03.2015 01/00 8000 COMPLETION OF
MATE MATE
CONTRACT
JDPO

CS OFFSHORE MDPL ANJALI MPSV 3542 KPOS DP 205 30.01.2015 21.02.2015 00/23 5915 TRANSFER TO COMPANY
22 SECOND VESSEL
MATE
JDPO

CS OFFSHORE MDPL CONQUEROR AHTS 2558 BRIDGE 100 SECOND 11.12.2014 30.01.2015 01/21 8000 TRANSFER TO COMPANY
MATE MATE
VESSEL
JDPO
Ver 1.0 Rev 00 Date: 01-Apr-2018 Page 6 of 7
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MILAHA SHIP MANAGEMENT
APPLICATION FORM MSM – OOV – SM - 151

Please use separate sheet for any Major Incident / Observation / Special experience for reporting: