GEM Form

No. 501
NEXT OF KIN OECLARATION
~
GEM
(Ref: MPM 04)
Revision #00
Dated 28 Feb 2021
CJULI· t:Nt:HbY MAHlltMt l'Jlt.- , of death of the crew member
f
prior joining a GEM vessel • ( nl case
Thfs form will be completed by all crew members every time ' . O
• / ompensatfon to the next ot
Off
. will be used as guidance for settlemen t c aim c o
while engaged on board, the attached document • b k ron
1 to the Manning tee
. by the crew member pnor em ar a
km. However, any other legal document signed and submitted
other Legal Authorities may take precedence as per statute.

Name of seafarer ARYAN_ SINGH t1ATf-l ARV

Nationality I rJ orJIN_
Rank
c~- - Joining Date f
;2-J f 10 .l. Lt
Joining vessel GoL F _Cof2..Al
as follows
First point of contact to be notified in case of Emergency,
- - • -- _ __,1;._____:1"~q~,~8~~~ .1~1~~ ~0~_L ....l--- --,
Tel
Name ~
Ko.nan M
event of my death during my tenure
I, the above named crew member, solemnly affirm that in the
if any, should be to
on board the above mentioned vessel, compensation amounts payable,
Balance of wages and personal effects
the following persons as per percentages indicated below.
No. 1 in below table
should be given to my next of kin whose name appears at serial
percentage
I
Relation Date of Birth Adress / Contact no. - - - -
Sno. Name -
- - 100
1 Mo.t'\"t -f_(.t .Ko.wt... Mot>Jt:h : 3ll~/ 10 •9I q1qg I C.,7 3\..\ 2.
2 I
I
3 •-t-
'
I

4
I

I I
5
I
I I
d in above table)
Information regarding spouse and Children (if not already include
1
Relationship date of birth
Names

Signature of Seafarer ~~_St"3 h Date Ja1J tl2~_ Place _Ahrn t£k_b ~

Thumb impression
(If required)
Left thumb Right thumb

Witness 1 Name Signature

--------

Witness 2 Name Signature

Personnel officer I Superintendent at GEM

Important Note: Uncontrolled if printed (MSM 04).

 GEM Form
No. 558
Personal Travel
9
1~

Evaluation Revision #00

Dated 28 Feb 2021
GEM (Ref: MPM 04)
GULF ENERGY MARIT UIE NSC

Security Policy
Personal Travel Evaluation - Maritime
Of movem
ent but additional
risk d~e to the natu re . l ·t or religion. A
rity 1
Travel carries a residual level of secu ~l duce any
destinat10ns due to race, natJona .
risks may be associated with specific subs tantt a Y re
to individual needs, should
common sense approach, adapted
heightened risk.
Hazards

unaware of surroundings;
1. Unfamiliar location - Disorientation and d t l in
s or disclose company business; Y.
2. Do not offer bribes to local authoritie local customs and religion, dress mo era el
of
3. Local customs - Be respectful politics or re tg10n
compliance with natio nal laws , be polite and courteous. Do not discuss
. . . d co of
in public; date , prescribe d med1 cat10n an PY
are up to
4. Illness - Ensure vaccinations
carried;
prescription, basic first aid remedies . d
icatio n - chec k coun try requ irements with Consulate or airline; 1se
5. Illegal med agen ts h~ve been adv
flights have been booked and
6. Travel arrangements - check that n and transport
of travel, mee t and gree t proc edur es in place and onwards accommodat1o
emergency phone numbers;
to the vessel arranged. Ensure you have
re all docu mentation for travel is obtained;
7. Passport and visa control - ensu .
to allow checking at security;
8. Electronic devices - easily access ey and elec trom c
surroundings and keep valuables, mon
9. Theft, pilfering - be aware of
;
goods secure. Keep valuable out of sight insect
insec t bites - wear appr opria te long sleeve shirts and trousers. Have
10. Mosquito and ing;
weather precautions and cloth
repellent in your luggage. Consider cold ted with
from dogs , cats and wild animals which may be infec
11. Animal bites - Keep away
immediately;
rabies. If bitte n report to the Master dairy products,
and wate r - Eat food from resta urants, ensure food is cooked, avoid
12. Food quan tities of alco hol and wash
hydrated, avoid large
drink plenty of bottled water, keep
hands regularly;
os, body piercing or needles
13. HIV or Viral Hepatitis - Avoid tatto
se - Use latex condoms;
14. Sexually transmitted disea d dark unlit or
and red light areas - Avoid being out alone at night, avoi
15. Night clubs, bars rban ces;
ns, political rallies and civil distu
remote areas. Avoid public demonstratio tered taxi service not
16. Travel - Use approved, arran
ged transportation such as a regis
and kidn ap in high risk security
personal security
unmarked cars. Be aware of possible offer ing or requ estin g you carry
ne approach ing and
areas. Be wary of strangers or anyo
items for them. es, do not pick up
doors locked, do not use mobile phon
17. Car hire and driving - keep all bles out of sigh t even when the
drive and keep valua
hitchhikers, do not drink alcohol and
vehicle is locked. lt people.
ult situations and do not swear or insu
18. Stay calm if confronted with diffic
tance, remain calm
the victim of an attack, offe r no resis
If, despite the~e precautions, you are Hand over wha teve r possessions are
are made of you.
and comply with whatever demands ld you become a
asing your chances of being hurt . Shou
d~~anded. If you resist yo~ are incre - this is non-threatening
t a posture of "no resistance"
V1ct1m of an act of aggress1on, adop onst rate com plian ce.
palms open to dem
body language with hands raised and

(MSM O◄).
Important Note: Uncontrolled if printed
Page 1 of 1
 GEM Form

•
No. 534
Details of Seafarers Bank Account Revision IOO
GEM Dated 28 Feb 2021
GULF ENERGY MARITJME PJSC (Ref: W'M 04)

Instructions
This form Is to be filled In by the seafarer and to be submitted An
• Ina vessel.
t everytime prior j 01"
to the Mann Ing MSen :,
Please complete part A QB Part B of this form as applicable f u pleted and submitted
. Part A must be u Y com ,,
whenever there 1s a change of bank details, "currency In which " "C r enrv in
account Is he Id or u r ~, which you wish us to pay you •
Bank account once nominated pnor joining should remain
unchanged throughout the tenure of engagement.
One month notice must be given if Account is to be changed
for any specific reason

Name of Sea{arer
A~OJ \ s:~ M,:11-,Q NA
Employment ID: E;;CM 0.3.5'~ Date of Birth: os Io q I .20
Nationality -r. ,
J.\'\C l..t~ ,---- --
Passport No. y ~C, 16 ~, ~
Rank : --~~"- -=Ca~ clttlW !lt----J oining Vesse~l:_ _~e-~o~L
~Ec__~C~o~R~.4-=L=---,
Contact Details (for Bank·s notification of fund transfers
):
Email address should be entered to facilitate the auto bank
notice to seafarers on pay'!!_ent
Email:

Mobile Phone: qqC\ 955"0168

Part A l Bank Account details
I All fields below are mandatory I
Name (as in Bank register) A---~ \ Si1\qh ~
,·t'l,l,f,Ar

IBAN I Account Number: -

011-
- 2.gC\S -76 - 006
-- - -- -
Currency in which ✓--

account is held: INR / USO / EUR / PHP / BOT / LKR / Other (Specify):
Currency in which you -✓- - - - - - - -
wish us to pay you: INR / USO / EUR / PHP / BOT/ LKR / Other (Specify):
'- - -- - -
Name of Bank and Branch
- - -
HSBC. ~etnk , &x~ (ult-Stj Mu~
Branch Bank Code I IFC Code
f-tSBC. Olt 06oO Lt
Address
r\Se,c. Ce.n'LiLl °'1..AF"f\bed.tl°"'- P.o°'e\. Bo.~ Cwes-t) I
I
City and Country ~bo_ ;. ,:I:nctlo.. ,

Swift Code ltS BLTNC.1 f> Sort Code Route Code

Correspondent Bank Details Et Swift Code:
-
Please note for INR transfers IFSC Code is mandatory and for
other currencies, swift I Sort I Route code is mandatory

Part B l
I have already declared my Account details

on while joining
Date
Name of Vessel
The details given at THAT TIME have NOT changed .

• _A~r) • Srn!3 h. .....

Signature of Crew Member
Date and Place
1
Important Note: Uncontrolled if printed (MSM 04).

,mpu, LClllt. l'IVU•• ............

 GEM Form
Pre-Joining COVID-19 No. 560

• GEM
GULF ENBRGY IIARITlllE PJSC
Wellness Declaration
(Ref: MPM 04)
Revision #0C
Dated 28 Feb 2021

Seafarer's or Contractors, 2nd and 3rd Party Auditor and Inspector's Self Declaration:

I hereby declare that in the last 14 days:

• I have not had a persistent high temperature or symptoms of fever (Temperature >38C
- 100.4F)

• I have not had a sore throat or suffered any loss of taste or smell;

• I do not or have not got a persistent dry cough;

• I do not have a runny or stuffy nose;

• I have not had or do not have any body aches or pains;

• I do not have diarrhoea, conjunctivitis or suffering from headaches;

• I do not have a skin rash or discolouration of fingers or toes;

• I do not have any difficulty in breathing or have experienced any shortness of breath;

• I do not have chest pains or feeling chest pressure;

• I do not have any loss of speech or movement;

• I have not had any close contact with a person or family who has been diagnosed or has
Covid-19 symptoms.

I have not travelled to or from another country which has infections within the past 14
days

This above list is dynamic and can be updated by Manning Agents, 2nd or 3rd party inspectors as
per guidelines issued by the latest WHO updates and sent to the crew member of h1s joining.

Contractors, 2nd or 3rd Party Auditor or Inspector are tc provide this Wellness Declaration
minimum 24 hours prior to boarding the vessel.

I have read GEM Safety Alert 09-2020 which is attached and made aware of precautions to be

l taken to keep myself healthy.

Name: ¾an s; ~h Ml.thOJJM Rank: lh:k CGdd.

Vessel assigned: GuL F COAAL

Signature: A.npn 5;n3b Date

Important Note: Uncontrolled if printed (MSM 04).

Page 1 of 2
 GEM Form

Pre-Jointng COVID-19 No. 560

•GEM
GULF ENER GY ltlARJTIMB PJSC
Wellness Declaration
(Ref: MPM 04)
Revf sf on #0C
Dated 28 Feb 2021

Manning Agents:
the details of
travel the following rules apply and
• Whenever a Seafarer is requested to w.
d in the table belo
travel requirements are to be complete
Details
Info rma tion Required

or 3rd Party
Name of Seafarer /Contractor /2nd
Auditor or Inspector
el
Countries of residence I origin of trav
ks
Countries visited in the last two wee
or port of
Destination country, Joining Port
Inspection

Connecting countries/ Airport

r oc Date: ....... 1......... / .......

Body Temperature minimum 24 hours prio
boarding the vessel

vessel oc Date: ....... ! ......... ! .......

Body Temperature on boarding the

illness for
Pre-Existing medical conditions &
the last 14 days

(Date)
Master)
(Signature of GEM Crew Manager or
ctively.
• Wash your hands regularly and effe people who are
t two met er away during self-distancing or fronJ
• Try and stay at leas
coughing or sneezing. ng unwell, consult
contact with other persons. If feeli
• Avoid crowd and any unnecessary
doctor Immediately.
lopments on COVID
• Keep yourself appraised of latest deve

Note:
• Original to be retained n joining the vessel.
declaration and carry it with him whe
• Seafarer to retain a copy of the

ted (MSM 04). Page 2 of 2

Important Note: Uncontrolled if prin
 GEM Form

~
No.504
Pre-Joining Declaration -

(Ref: MPM 04) Revision #OC

GEM Dated 28 Feb 2021
GULF ENERGY MAR17YME PJSC

I hereby agree to follow the following declarations:

1. MLC Declaration:
This is to confirm that
• I have received a copy of my employment agreement.
• I have been given an opportunity to examine the employment agreement and
have the contents explained to me.
• I have been explained and have understood my rights and duties as per the
relevant agreement under which I am being employed.
• I have signed the contract/Letter of Appointment of my own free will.
• The expenses towards pre-embarkation medical examination have been paid
by the company and not by me.
• I have not paid any fee or incentive (in any form) either to the Company or
to any employee of the Company or any agent / broker to facilitate
employment.
• Any visa cost for port of joining has been incurred by the Company.
• I have been informed that the vessel is MLC 2006 compliant

2. Marine Pollution Prevention Declaration:

I hereby agree that during my service on board I shall not knowingly participate in any act of
pollution contrary to the legal and company requirements unless it is carried out for the safety
of the vessel or safety of life and under the Masters (or person in command's) explicit orders.
I also agree that if I become aware of any act of pollution (whether intentional or
unintentional) I shall immediately report this to the Master/the Company. I am aware that I
may be subject to dismissal from the ship if found to have knowingly taken part in any act or
suspected act of Marine Pollution from the vessel in which I am serving.
I am also aware that I may be subject to Criminal Penalties by relevant National Authorities in
whose waters the pollution occurred and therefore 1t is in my own interest to comply with the
intent of this declaration.

3. Drug and Alcohol Use Declaration:

I am fully aware and do understand that the owners of my vessel are signatories to the U.S.
Sea Carrier Initiative Agreement which was signed in connection with the U.S. Anti-Drug Abuse
Act 1986. I am also fully aware that the Company has a Drug and Alcohol Policy as per OCIMF
guidelines of January 1990. In this connection, I hereby confirm that:
• I am not and have not been addicted to any drugs and am not a drug user.
• I will not be engaged or connected in any way with drugs or peddling of
drugs.
• I will fully cooperate with the relevant authorities in all ways to avoid
smuggling or trafficking of illegal drugs.
• I have been made fully aware of the Company's policy on Drug and alcohol
abuse, have received a copy of the same and undertake to abide by it.
• I will if required, submit myself for thorough medical examination. This to
include random testing for drugs and alcohol as per Company Drug and
Alcohol Policy

Important Note: Uncontrolled if printed (MSM 04).

Page 1 of 2
 a ; ,a ,n aztEX1AFIF7 «fiib4™™

I
GEM Form

~
No. 504
Pre-Joining Declaration . "

(Ref: MPM 04) Revision #OC

GEM Dated 28 Feb 2021
GULF ENERGY MARIT1JIE PJSC
C
~

!n
If I should be found in unlawful possession of drugs, I hereby undertake to pay full all claims,
damages, costs and expenses whatsoever which may be taken or made against the Owners,
including my repatriation and my relievers joining expenses.

4. Medical Health Declaration:

I declare that I have not suffered any major injury or sickness since my last company medical
done on _ _ _ that would preclude me from working in an effectiv~ manne: _on board
company vessel. This is to state that I have been prescribed the followmg med1cmes by a
medical practitioner for use on board:
1)
2)
3)
4)
I am aware that if I am in need of any medical attention on board the vessel, I am to inform
the master and follow the course of treatment prescribed by the master and / or doctor. I am
aware that if during the course of my employment it is found that I am consuming medicines
without the approval of the master / company, such act on my part is considered a material
breach of the terms and conditions of my employment which could justify dismissal.

5. Responsibility of Confidentiality Declaration:

I understand and agree to maintain and safeguard the confidentiality of privileged information
of GEM. Further, I understand that any unauthorized use or disclosure of information residing
on the GEM information resource system may result in disciplinary action consistent with the
policies and procedures of GEM and local agencies.
The above declarations have been made by me truthfully without duress and of my own
free will on this day.

Name:
~h slnab M<ilbo.n.u
Vessel Assigned: Rank:
G:Ul E C,oRAl De.ck Cachl
Signature: Date:
~" s;;N3b tR I tol 2. ¼

Note:
• Original to be retained
• Seatarer to retain a copy of the declaration and carry it with him when joining the vessel.
• This declaration is only in force from the date of signing on article of agreement until the
date of signing off.

Important Note: Uncontrolled if printed (MSM 04).

Page 2 of 2

~an.S \~h
 -...,.
Oull !ofra, Maatu e w

Stamnent Of Rettipt 0/ Doamtffltl

This is to put on r@cord that I have received the followifll from mannina apnts Selandia Crew Manapment (lndll)
Pvt, Ltd.

A. I confirm that I havt read and understood the contents of the atreerMnt and haw no further queries with reaard
to the terms and conditions of my employment

1. Letter of Guarantee.
2. Seamanfs Employment Contract.
3. Appointment letter
4. Declar:atk>n aaalnst u~ of Drugs & AlczohOf
S. Medical Declarabon.
6. Letter conta,nlng Important Cont.a Numbers
7. Envelope containing the introduction lfflet to the M.tstet alonl with lht o,~naf Medkat reports for hand;n1
over to the Master upon boatd,,w the msel
8. Contact list lncase of ,meraencywhibt tthel1ffll
9. GEM Form ·508 - Lett~r of under talc,fW by seaf,m
10. GEM Form 504-Marine PoUubon ptevtnhon DtditiliiOn
11. Grievance r~ressal Mec.ham5m for seafam DG art ,
12 Gnevance r;edressa1 Offi~rof~and.a undffltood
l3. Chaplet -4 -Mannln_gol mps, Anntd Term & ,vnvt of Employment

8 Travel tld(e1+ joining ~~ns;c,, Pit}.w,otl St1m1n, Bed JO

C. He11th Book. with v11td YeUow fevH v1ron11 oo
O Job descripbon -latc.s, Rev,~1on
f rurthN ,tate that Ihave
1 AU mv orii,&tnat proft's~ onal doromenu ind srcw rert fi~te-s w 1h me wh ch I w f be carrvins to the vtmf
2 Pald My MUl/NUSt memt>e~tp tees
MUI/NUS1 Mtmber~lp No Val d urm>
Receipt No Rs

Signatu~ of Seafarer

D1te • lg hO f1 't
 _.._ II ,llli"l th,

Follo"'ing conctm, raised aboua lhe environmental tmplC'I of pcnrn~iible dasct.gcs from tankm car-
rying N<>J1ou, Liquid Substancc:s (NLS). MEPC 74 ,n Ma) 2019 adopttd ~ Wa) of IMO Resolution
MEPC.315174). 1mendmcnts to MAR.POL Anne~ II so strmgthen d,sctuqc ttqutmntntJ
ror cargo l'Ciiduo aild tank w'Wling, from such ~n~ts

Spctlfall). stnctn ptt "•shmg PfO'.WUR' rcquu,mrnts ha\~ bcrn

GEM
htdlrn<r N,mc ( Jt ,,
rodu«d for dis.charges c~mtnR pmi~cm Ooet,nM ~ t J
Sttnt floatcrhf \\Ith a high•'1~1t) and or a hlah mflltnl point
an sotid1f) under ctttam ronchtiom. uampla mcludc ccnaln \tgt·
bit o,ls and paraffin like cat~
lhe pt "'<ashmi n-qmrcmcnb "hall Aflfll} ,,htn lhc \t,~1, ate ,~ith•
n I defined area Mte1Chmg from Otbtaltar in the ~uth all tht "•> alon1
'-tn--rgian c ~ 1n(hwf n2 the Balh" Sea.~ "tll a5 the l I\ ond Ir~
nd
thcmtcai tankers con~r\l\:ttd on ffl' after I Jul) I'>36 a,, ~ubJt'\:t to
- . -• the Intcmat ml tode fot t~ Con~trwtron and t<1u1pmcnt of Sh1Jli Cot•
I
•
. ( '
'
•

•
&• •
. r)mg Oangcrnu~ themKaf~ t Bulk t IUC Code 'l
•

, .... ,:.
..

.. • Tbf lBf t
. .'
, ~ ~
t fi,rthc ~.,tc
-. . - . . b\ ~ n hulk Ml
ad ~~',m',"K..'.., dmcnti 1 , c\ n
peer I Gmtroduccd
f M \MNJl \nnc,
nt floatcn I h

ri 1 •e: 01 crou
)t u chc c;ink.•
( rth;;vn 111111:
f)
• A\lh fhnc , I
lhepr f ltnc "
onch ndment!I rtM:
n~ IU have 1he 8ilffi('
0..1)1 ex cerof1cutc,
l
• AmMded OEM chem ~ul cla ,e ,el und
ha~beendl
• \\ 1,cn e:tft--O is th . d.itt. the: relevant prO\' 1 Ion
af1hc mr. Code st 1he betn unloaded
• lltr ftmt'fldmr-m_) 1 dlC' 18C the of tile vencl 1 r
and Amm !MlCnb tP& an: r \\illh their Cl on
~ 1e11es fot unlt"l} tt"\1 a;,proprwe. o t lf ranker • P&A manu:tl 10
llh.'iudcomendmentsl MEPC'Jl5(7.:& pnortoltE' t January 2021 impfrt11t tall nd1,;adline
• Amendmt'.nh m P&A "13nU3h oo GEM iltti ·n·sseh hld bttn inmated Thne "ere m~11nl) c 1r-
nC'd om and completed dunn,s Chis r~ ~ the \e55clj. f.t. Annul Uf\'e)I~ except fo, the
,'CSsd Gulf~luttr1h. \\h.cch b )cf toi:omp 1s

MIi\ "" also mention that effn"t1\'f' 1st Jw Wif) 20'.! I, tht ,esxl are to mamtain Statement~ of Com..
phancc cm lm'.Cntof) ofHua.rdous \lattriah, tlH\11 P~ be rent"nded 1h31 Cm1fict1tts are t be
rruunuuncd on board. mdudmg file" th frr.rruot) ofHal.ardous Mawtab

------lll((_____ J_o_m_ha_n_d_s_to_sa_v_e_en_v_,~_o_nm_e_n_t__.,,,,,,.)--.--~•

I - I