VM/FO/P/001

VRIDHI MARITIME PVT LTD REV.NO:00

DATE:06-07-
2017
Application for employment
Page 1 of 5

Application for Employment Use Ball Point Pen Only

First Name Middle Name Last Name/Surname

Nationality Date of Birth Place of Birth

Height - CMS BMI - Marital Status PHOTO

Weight- KG

Post applied for Willing to accept lower Available From:

Yes No
Permanent Address: Present/Temporary Address:
Until:

Post Code: Tel: Post Code: Tel:

Nearest Airport: Nearest Airport:

Document No. Is Place Valid Until

sued

Passport: Country

Seamans Book (CDC):

National

Seamans Book (CDC):

Others

Indicate type of valid visa USA C1 Yes No valid until D

Yes No valid until
Name of Nominee for compensation in case of fatality: Relationship:

Add:

City: Post Code: Tel

Family Data:
Relationship First Name Last Name Date of Birth Passport No. Issued Place Valid Until

Spouse

Child M f

Child M f

Child M f

Child M f

Child M f

ORIGINAL: OFFICE RETENTION PERIOD- 5 YEARS

COPY: NOT TO BE KEPT in VESSEL
 VM/FO/P/001
VRIDHI MARITIME PVT LTD REV.NO:00
DATE:06-07-
2017
Application for employment
Page 2 of 5

Indicate type of valid visa (1) USA Canada Brazil UK Others

Certification as mentioned above and is checked for accuracy and authenticity.

_________________________________ _____________________
Manning representative Date Signature and Stamp

CERTIFICATES/COURSES:
Highest Competency Certificate Held:

Issuing Authority: Grade (1) Certificate Date Issued Place Issued Valid until
Number

National (Country )

Panama

Hong Kong

Others:
(1) Specify whether: Deck Class 1= Master FG Engine Class 1= 1st CLASS (M), (S), (M+S) R/O RT only
st
2= 1 Mate FG 2= 2nd CLASS (M), (S), (M+S)
3= 2nd Mate FG 3=
4= 4 = 4 Class4 (M), (S), (M+S)

Other Certificates held and courses attended:

Course/Certificate Certificate Date Place Valid

Number Issued Issued Until

Personal Survival Techniques

Proficiency in Survival Craft & Rescue

Boat

Elementary First Aid / Medical First Aid

Ship Masters Medicare

Fire Prevention & Fire Fighting

Fire Fighting Advanced

Personal Safety & Social Responsibility

Radar Observer

Radar Simulator

A.R.P.A.

Ship Manoeuvring Simulator

Engine Room Simulator

Liquid Cargo Handling Simulator

BTM

G.M.D.S.S.

G.M.D.S.S.(STCW 95) ENDORSEMENT

ORIGINAL: OFFICE RETENTION PERIOD- 5 YEARS

COPY: NOT TO BE KEPT in VESSEL
 VM/FO/P/001
VRIDHI MARITIME PVT LTD REV.NO:00
DATE:06-07-
2017
Application for employment
Page 3 of 5

INDOS
Others : YELLOW FEVER
PSSO

Pre Sea /Educational Qualification

Course Details/Institution Certificat Date Place Valid
e Number Issued Issued Until

Watch keeping Certificate: (for ratings only) Include Flag state Qualification
Certificat Date Place Valid
Certificate Details
e Number Issued Issued Until

SEA EXPERIENCE: (Last 5 years) (Most recent experience on top line)

D D
C Vess T Main ate From ate Duration
To
ompany el ype Engine (1) d d
d/mm/yy d/mm/yy

(1) Engineers to give make/model of engines, e.g. MAN 14V52/55A or SULZER 5RTA58

For Office Use ONLY ASSESSEMENT OF CANDIDATE DURING INTERVIEW

Appearance Attitude English

ORIGINAL: OFFICE RETENTION PERIOD- 5 YEARS
COPY: NOT TO BE KEPT in VESSEL
 VM/FO/P/001
VRIDHI MARITIME PVT LTD REV.NO:00
DATE:06-07-
2017
Application for employment
Page 4 of 5

(on a scale of 1-10) (on a scale of 1-10) (on a scale of 1-10)

Scale / 10 / 10 / 10
Remarks

_________________________________ ____________________
Name and Signature of Interviewer / Date and place
Manning Representative

MEDICAL HISTORY

It is of utmost importance that all illnesses other than minor afflictions should be stated. The Company is entitled to refuse any claim for
treatment, cost or any other insured benefits if a complete statement of all previous illnesses has not been given.

(A) Have you ever signed off a ship due to medical reasons? Yes No
If yes, please provide following details:
Name of vessel Date of occurrence Place of occurrence

Brief description of illness/injury/accident

(B) have you undergone any operation in the past? Yes No

If yes, please provide following details:
Details of operation Date Period of Present condition
disability

(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?

Details of illness Date Therapy/Treatment

(D) Please give details of any health or disability problem

Details of illness

BANK/PENSION SCHEME/MEMBERSHIP DETAILS:

Bank Name MUI/NUSI
Address Membership No.

Account Name
Account No.
Sort Code

GENERAL
(A) Have you ever been denied a foreign visa? Yes No
If yes, state which country and reason (if known)
(B) Have you been the subject of a court of enquiry or involved in a maritime accident? Yes No
If yes, please attach details

(C) References
ORIGINAL: OFFICE RETENTION PERIOD- 5 YEARS
COPY: NOT TO BE KEPT in VESSEL
 VM/FO/P/001
VRIDHI MARITIME PVT LTD REV.NO:00
DATE:06-07-
2017
Application for employment
Page 5 of 5

Please give references from two recent employers who we may contact for references
Reference 1 Reference 2
Name of Company
Name of person to contact
Address

Country
Telephone

I hereby declare that the above, including Medical History, is true.

Place: Date: Signature: ________________

ORIGINAL: OFFICE RETENTION PERIOD- 5 YEARS

COPY: NOT TO BE KEPT in VESSEL