APPLICATION FOR EMPLOYMENT

Note: Please fill up the all the columns in this form in bloc letters! " Position Position applied for: Are you willing to accept any other positions? #ro$ what date will you %e a&aila%le? # Personal Particulars Na$e: )*ast Na$e+ Date of -irth: Place of -irth: 'arital tatus: E$ail Address: Per$anent address: (AND"N )#irst Na$es+ PRI(I , ./ 'AY 0123 Nationality: INDIAN A4'ER5 INDIA Age: .6 ING*E Religion: ,IND7 pritisht8g$ail9co$ /1:;!..5NE< =E ARI >"*"NY5 ADAR , NAGAR5 A4'ER5 RA4A (,AN Post code: 3:?::. A'E A A-"@E Post code: No
+ 9 1- 145268 0 2 8 1 , + 9 1 9 7 9 9 1 1 7 9 2 4

3RD ENGINEER N" YE !N" I''EDIA(E

'ailing address:

No9:

Please enter countr$ % area co&es

'

Famil$ (ac )roun&

NEA( "# =IN : RE*A(I"N ,IP : *ast Na$e+ (AND"N )#irst Na$es+ 'AD,7 Na$e: /1:=!..5NE< =E ARI >"*"NY5 ADAR , NAGAR5 A4'ER5 RA4A (,AN5 INDIA Address: >ontact telephone nu$%ers:
Names of Chil&ren 0st9
91- 145- 2680 2 8 1

'"(,ER

Post code: 3:?::. 919 4 6 0 2 4 2 0 3 7 .nd *e+ ,ate of (irth

E&ucation./ualification

chool ! >ollege
("*ANI 'ARI(I'E IN (I(7(E .::/

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,ighest Bualification Attained

-9 'ARINE ENGINEERING9

I&entit$ &ocuments ,OC1MENT Passport: CO1NTRY CCC N1M(ER D.?30:.2 I**1E, CCC .0!0.!.:0. PLACE CCC 4AIP7R '7'-AI NE< DE*,I E2PIRY CCC .:!0.!.:.. 06!:?!.:06 :3!:?!.:06

INDIA

ea$an ID INDIA '7'0/.6:? 02!:?!.::6 Discharge -oo; Do you hold a 7 @isa E>0F? YE !N" YE 06!:?!.:0. Do you hold a 7 @isa EDF? YE !N" ,a&e you %een reGected for any &isa applied for? YE !N" N" If YE 5 please state the country and reasons

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Certificates (Highest certificate of competency held) >lass ! Grade >*A . Issuing >ountry 7NI(ED =INGD"' >ertificate No9 >o>::3.:?1 Date Issued .:!:3!.:03 Place Issued 7= @alid 7ntil 30!:3!.:02

,an)erous Car)o En&orsements (ype Petroleu$ *iHuified Gas *iHuid >he$icals

OT5ER OIL T6R*

>ertificate No9 E:3:?3?

*e&el "PERA(I"NA*

Date Issued .0!0!.:0/

Place Issued INDIA

@alid 7ntil ..!0.!.:03

Courses atten&e& an& certificates obtaine& 'odel 0 . 3 / ? 3 6 2 1 0: 00 0. 03 0/ 0? 03 06 02 01 .: .0 .. .3 ./ .? .3 .6 >ourse Ad&anced (an;er #a$iliariIation Auto$ation and >ontrol Practical 'arine Electrical <or;shop 'odular *iHuefied Gas (an;er Ele$entary #irst Aid 'edical #irst Aid Personal ur&i&al (echniHues -asic #ire #ighting ,u$an Relations J P R Ad&ance #ire #ighting Proficiency In ur&i&al >raft Engine Roo$ i$ulator hip -oard afety "fficer Institution PEN(AG"N I'(> I'(> "ER> ("*ANI N 'ARI(I' ("*ANI ("*ANI ("*ANI ,I'( **(EE=AY Place '7'-AI '7'-AI '7'-AI '7'-AI P7NE '7'-AI P7NE P7NE P7NE >,ENNAI '7'-AI '7'-AI '7'-AI Date 0?!0.!.:00 0/!:2!.:0: .0!:2!.:0: :3!:2!.::6 :2!:?!.::? 02!:6!.::1 03!:/!.::3 0:!:?!.::3 :.!:/!.::? 03!:?!.::1 :.!:?!.::1 ..!:/!.::1 :/!:1!.:03 >ert9 No9 P'(RI!(A >"!0.!00!.:0. A7("!03C0C!0/23 P'E<!0?C0C!023. *G(#!.623!.::6 ('I!E#A!:?!0/!.6: 'I!'#A!036/!.::1 ('I!P (!:3!0:!0?: ('I!#P##!:3!0.!..: ('I!P R!:?!0/!.6: A##!-.06!0/ :1:/.6 :1::31 :3:!.:03!'7':.2 @a lid

C1RRENT EMPLOYMENT Na$e of E$ployer Address of E$ployer Period of E$ploy$ent (o <ho$ Responsi%le 3:353 #*""R5 *EE*A -7 INE . YEAR
rd

(EE=AY 'ARINE *I'I(ED PAR=5 AND,ERI =7R*A R"AD5 'AR"* PIPE*INECAND,ERI >urrent Position E+pecte& *alar$ 3RD ENGINEER /3:: 7 D

*ast Drawn alary /3:: 7 D "ther Allowances Reason for *ea&ing >*EARED >*A <hen would you %e a%le to enter our e$ploy$ent if offered?

. AND *""=ING #"R PR"'"(I"N (" NEA( RAN=9 YE

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"9

Me&ical histor$ ,a&e you e&er signed off a ship due to $edical reasons? ,a&e you undergone any operation in the past? ,a&e you consulted a doctor during the last 0. $onths for an illness!accident? Do you ha&e any health or disa%ility pro%le$s? YE YE YE YE ! N" ! N" ! N" ! N" N"

NO NO NO

)If the answer is YE to any of the a%o&e5 please gi&e full details and attach a separate page if necessary+

""

:eneral Re$ar;s ,a&e you e&er %een the su%Gect of a court of enHuiry or in&ol&ed in a $ariti$e accident? ,a&e you e&er had a professional license suspended or re&o;ed? Do you ha&e any physical defects!$edical illness!chronic disease!$ental illness? Are you colour %lind ! deaf? Do you depend on any $edication? Are you declared %an;rupt? ,a&e you e&er %een e$ployed %y 'I > -erhad or its Group of >o$panies? Gi&e details of any E%ondF or o%ligation to ser&e the go&ern$ent or any other %ody )including period of contract+ YE ! N" YE ! N" YE ! N" YE YE YE YE ! N" ! N" ! N" ! N" N" N" N" N" N" N" N" N"

YE ! N"

Does your e$ployer ;now you are thin;ing of lea&ing? YE ! N" YE ,ighlights any achie&e$ent attained in your pre&ious and ! or present e$ploy$ent I ,a&e %een already appro&ed for pro$otion %y the &essel $anager %ut awaiting &acancy to %e pro$oted to neKt ran; %ut ince I ha&e a class . license I a$ loo;ing for opportunity to %e pro$oted so that I can ad&ance $y career9 Please state here any additional infor$ation which you consider to %e of assistance to us in assessing your suita%ility for the position applied: I A* " ,A@E -A,A'A AND 'AR ,A** I *AND >D> A <E** A >RA A* " ,A@E A @A*ID >,ENGEN @I A 7N(I* 0/ APRI* .:0/

)If YE 5 please gi&e full details and attach a separate page if necessary+

"#

References (Please give the name and address of your current or immediate past employer) Na$e of co$pany Na$e of person to contact Address Reference " TEE6AY MARINE LIMITE, POONAM M1R6AR! '9';LEELA (1*INE** PAPAR6;MAROL;AN,5ERI<61RLA ROA PAR6;AN,5ERI;M1M(AI Reference #

No9

=8"<##<3""#--40

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In Case of Emer)enc$

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Contact Person " Na$e Relationship Address

Contact Person #

No9

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,eclaration I here%y declare that the a%o&e particulars are true and authorise you to contact the referees listed a%o&e9 If e$ployed5 in the e&ent of a disco&ery of any $isrepresentation of acts5 willful or otherwise I will %e su%Gected to su$$ary dis$issal9

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Date: ignature

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Recor& of pre>ious ser>ice ? Must be fille& @Please )i>e a full recor& startin) Aith the last >essel on Ahich $ou ser>e&B CE**EL COMPANYD (EE=AY (EE=AY CE**EL TYPE DPC. ,7((*E (AN=ER A#RA'AA (AN=ER *IG,(ERING (AN=ER 7ED'AA FLA: -A,A'A -A,A'A ,ET 3::.3 3331/ YEAR (1ILT 0111 .::/ MAIN EN:INE MA6E TYPE 'AN -< '> ENGINE <I(, >PP 'AN -< 'E ENGINE <I(, >PP R(A '> ENGINE '> ENGINE 'E ENGINE '> ENGINE '> ENGINE '> ENGINE '> ENGINE '> ENGINE (!5!P! .0/1: .0/1: RAN6 3RD engineer 3RD engineer 3rd engineer 3RD engineer 3RD engineer 3RD engineer 3RD engineer 3RD engineer ENG >ADE( ENG >ADE( ENG >ADE( *I:N ON ,ATE 0?!0:!.:0 3 .:!:/!03 *I:N OFF ,ATE 0?!:0!.:0 / :2!:6!03 ,1RATION @MM.,,B 3!3 :.!02

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Please ensure that the full na$e and address of your i$$ediate past e$ployer is entered in section 1

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Attachments Please attach copies of $our certificates % rele>ant &ocuments! Man&ator$ Certificates . ,ocuments: "! Passport #! Certificate of Competenc$ '! ,ischar)e (oo -! Me&ical Report 0! ,an)erous Car)o En&orsement 3! Certificate Authentication @to be pro>i&e& b$ Mannin) A)enciesB

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