Crew Employment Form
Employee Details
Certificates
Details of Sea Service
Others Details
RPSL No. : MUM 320
Employee Code
Rank Approved
Rank Applied For
*
--SELECT--
Master
Chief Officer
Second Officer
Third Officer
Junior Officer
Deck Cadet
Chief Engineer
Second Engineer
Third Engineer
Fourth Engineer
Junior Engineer
Trainee Marine Engineer
Engine Cadet
Electrical Officer
Electro Technical Officer
Electro Technician
Trainee Electro Technician
Bosun
Pumpman
Able Seaman
Reefer Man
Ordinary Seaman
Trainee Ordinary Seaman
Fitter
Motorman
Oiler
Wiper
Trainee Wiper
Chief Cook
Messman
General Steward
Electrical Cadet
Junior Cook
Trainee Seaman
Deck Fitter
Technician
Trainee General Steward
Steward
Crew
Additional Master
Additional Master
Additional Third Officer
Fourth Officer
Deck Boy
Gas Engineer
Electrical Engineer
Additional Fitter
Repair Team Fitter
Additional Wiper
Traniee Gas Engineer
Trainee Electrical Engineer
Security Guard
Date of Readiness
Last Name
*
First Name
*
Middle Name
Date of Birth
*
Place of Birth
Religion
Gender
--SELECT--
Male
Female
Nationality
*
--SELECT--
Bangladeshi
Belarusian
Bulgaria
Canadian
Chilean
Croatian
Danish
Estonian
Filipino
Georgian
German
Ghanaian
Honduran
Indian
Italian
Korean
Latvian
Lithuanian
Moldavian
Moldova
Montenegrin
Peruvian
Portuguese
Romanian
Russian
Singaporean
Slovenian
Sri Lankan
Turkish
Ukrainian
Marital Status
--SELECT--
Divorced
Married
Separated
Single
Widowed
DOCUMENTS
NUMBER
ISSUE DATE
EXPIRY DATE
PLACE OF ISSUE
Passport
Indian CDC
Nearest Airport
VALID VISAS
NUMBER
ISSUE DATE
EXPIRY DATE(YEAR)
PLACE OF ISSUE
US Visa C1/D
Contact Details
Present Address
PIN Code
Telephone No.
Mobile No.
E-Mail Address
Permanent Address
PIN Code
Telephone No.
Mobile No.
E-Mail Address
Family Details Details
Relationship
*
--SELECT--
FATHER
MOTHER
SON
DAUGHTER
WIFE
BROTHER
SISTER
HUSBAND
Passport No.
Surname
Date Of Birth
Name
*
Issue Date
Place of Issue
Expiry Date
EDIT
DELETE
RELATIONSHIP
SURNAME
NAME
DATE OF BIRTH
PASSPORT NO.
ISSUE DATE
EXPIRY DATE
PLACE OF ISSUE
Next of Kin Name
RelationShip
--SELECT--
FATHER
MOTHER
SON
DAUGHTER
WIFE
BROTHER
SISTER
HUSBAND
Telephone No.
Mobile No.
E-Mail Address
Certificate Details
Type
*
--SELECT--
STCW 2010 COURSES
VALUE ADDED COURSE
FLAG STATE CERTIFICATES
Certificate Name
*
Certificate Number
STCW Reg.
Grade
Issued At
Issued Date
*
Expiry Date
Certificate List
EDIT
DELETE
CERTIFICATE
STCW REG.
GRADE
CERTIFICATE NUMBER
ISSUED DATE
ISSUED AT
Expiry Date
Details of Sea Service
Ship Name
*
Oprerators
*
Type
*
--SELECT--
OIL - CHEMICAL TANKER
PRODUCT TANKER
CRUDE OIL CARRIER
VLCC / ULCC
OBO (OIL/BULK/ORE) CARRIER
LPG TANKER
LNG TANKER
CNG TANKER
LOG CARRIER
BULK CARRIER
GENERAL CARGO
CONTAINER
PASSENGER VESSELS
ETHYLENE CARRIER
OTHER DRY CARGO
Rank
*
--SELECT--
Master
Chief Officer
Second Officer
Third Officer
Junior Officer
Deck Cadet
Chief Engineer
Second Engineer
Third Engineer
Fourth Engineer
Junior Engineer
Trainee Marine Engineer
Engine Cadet
Electrical Officer
Electro Technical Officer
Electro Technician
Trainee Electro Technician
Bosun
Pumpman
Able Seaman
Reefer Man
Ordinary Seaman
Trainee Ordinary Seaman
Fitter
Motorman
Oiler
Wiper
Trainee Wiper
Chief Cook
Messman
General Steward
Electrical Cadet
Junior Cook
Trainee Seaman
Deck Fitter
Technician
Trainee General Steward
Steward
Crew
Additional Master
Additional Master
Additional Third Officer
Fourth Officer
Deck Boy
Gas Engineer
Electrical Engineer
Additional Fitter
Repair Team Fitter
Additional Wiper
Traniee Gas Engineer
Trainee Electrical Engineer
Security Guard
NRT
MT-DAYS
Flag
From
To
References
Type of Main Engine and BHP
EDIT
DELETE
VESSEL
OPERATORS/MANAGERS/COMPANY
TYPE
FLAG
RANK
NRT
BHP
FROM
TO
MT-DAYS
REMARKS / REFERENCES
Others Details
REF : 0
Deck Officers
Cargoes Carried
Trading Pattern
Engineer Officers
Type of Machinery
Pre-Sea Training
Academic Qualification
Percentage of Marks
Other Courses
Applicant's Medical History
Height in Centimetres
Weight in Kg
Has the applicant has ever signed off from a vessel on medical grounds? If yes, please furnish details.
Yes
No
Vessel
Reason / Brief Description of Illness / Injury / Accident
Date Signed off
*
EDIT
DELETE
VESSEL
DATE SIGNED OFF
REASON / BRIEF DESCRIPTION OF ILLNESS / INJURY / ACCIDENT
Have you visited the doctor in the last 12 months for any surgery / illness? If yes, please furnish details
Yes
No
Date of Illness / Surgery
Details of Illness and Treatment Received
Please answer the below, by ticking the appropriate box
Were you ever denied a foreign visa? If yes, please furnish details.
Yes
No
Are you willing to sail one rank lower ?
Yes
No
Do you have any history of accidents during your sea service ? If yes, please give details on a separate sheet of paper.
Yes
No
Have you been convicted in a court of Law (Civil / Criminal) ?
Yes
No
Are any legal proceedings pending against you ?
Yes
No
Have you been associated with any radical groups ?
Yes
No
Have any of your Certificates / Endorsements been Suspended or any procedding pending against you by any of flag state administration. If yes, please give details on a separate sheet of paper.
Yes
No
Assessment of Candidate during Interview
APPEARANCE(ON A SCALE OF 1 - 10)
ATTITUDE(ON A SCALE OF 1 - 10)
ENGLISH (ON A SCALE OF 1 - 10)
SCALE
REMARKS
*
Fields are mandatory
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