APPLICATION FORM

1 Position
Position applied for: Third Engineer
Are you willing to accept any other positions? NO
If YES, which positions would you consider?
Are you responding to a media advertisement? NO
If YES, please state which publication
From what date will you be available? As soon as

2 Personal details
Name: Kumar Deepak
Date/place of birth: 01-02-1982 Nationality Indian
Permanent address: : Uttar Pradesh
Village-Sujarai,Post-Kurawali,Dist- Mainpuri,

Post code: 205265 No.: 09917960306

Mailing address: Same as above

E-mail add: deepakmariner82@gmail.com Skype ID

Post code: No.: 8697078412,9193008112

3 Education Background
School / College From To Highest Qualification Attained
SSITM ,Aligarh 2004 2007 BTECH MECHANICAL ENGINEERING

4 Identity documents
DOCUMENT COUNTRY NUMBER ISSUED PLACE EXPIRY
Passport: INDIA H3503087 24-4-2009 BAREILLY 23-4-2019
Seaman book: INDIAN MUM167243 31-12-2009 MUMBAI 30-12-2019
Bahamian
Liberian
Panamanian
Marshall Island
Do you hold a US Visa C1/D? YES
Have you been rejected for any visa applied for? NO
If YES, please state the country and reasons

5 Family details

NEXT OF KIN Relationship: FATHER

Name: DAS (First Names) RAM
Address: Same as above
Post code: 205265
Contact telephone numbers: 1st. 9917960306 2nd.
Names of Dependants Sex Relation Date of Birth
Akanksha Chaudhary F Wife 18-01-1982

6 Highest Certificates of Competency held

 Class / Grade Issuing Country Certificate No. Date Issued Place Issued Valid Until
MEO CL IV INDIA 95Z/15407 12-11-12 KOLKATA 30-05-2021

6a Dangerous Cargo Endorsements-- (National or from the Original CoC issuing country )
Certificate No. Date Issued Place Issued Valid Until
Petroleum DCE01MUM17006120 27/10/17 MUMBAI 26/10/2022
Liquefied Gas M/G/1/E/15/28269 29/6/2015 MUMBAI 28/6/2020
Liquid Chemicals
Other

7 Highest Certificates Of Competency issued by other countries (Issued by countries other than in Section 6)
Class Issuing Country Certificate No. Date Issued Place Issued Valid Until
Liberia
Panama
Bahamas

Marshall Island

8 Courses attended and certificates obtained

Sr.No Course Institution Place Date Cert. No. Valid
01. Medical First Aid BP MARINE MUMBAI 6-4-11 BPMA/M/297/2011 Until
9-4-11
02 (Basic/Advance)
Personal Survival Technique
03 Basic Fire Fighting
04 Advanced Fire Fighting TS REHMAN MUMBAI 25-4-11 0020160152011 30-4-
05 Proficiency In Survival Craft & BP MARINE MUMBAI 12-4-11 BPMA/PSCRB/674/2 16-4-
Rescue boat 011 11
06 Fast Rescue boat course
07 Tanker Familiarization Basic ASHA VARANS 3-3-14 AIIT/OTFC/GN/D92/ 7-3-14
(Oil/Chemical/Gas) INTERNATIONAL HI 2023
08 Advanced Tanker Course:
a) TASCO BP MARINE MUMBAI 4/11/2014 BPMA/ATOT/833/20
14
b) CHEMCO
c) GASCO OERC ACADEMY MUMBAI 19-8-13 STPTLGT/1060/2013 29-8-
09 Ship Master Medicare course
10 GMDSS
11 Bridge Team Management
12 Bridge Resource Management
13 Liquid Cargo Handling Simulator
(LCHS)
14 Ship Handling Simulator Course
15 ECDIS
16 Radar / ARPA
17 Ship Security Office (SSO) BP MARINE MUMBAI 23-6-16 BPMA/SSO/733/201 25-6-
18 Ship Safety Officer
19 Engine Room Simulator COLG. OF KOLKAT 27-6-16 ERSM00360416 1-7-
20 ISM Code
21 DP / DP 1 / DP 2 /
DP Maintenance

22 ARAMCO Approval for DP

23 Vessels(Please specify)
Others
 9 Record of previous service
(Please give a full record starting with the last vessel on which you served)

VESSEL COMPANY# VESSEL FLAG DWT IMO YEAR MAIN ENGINE B.H.P RANK SIGN ON SIGN OFF SEA TME
TYPE Number BUILT MAKE TYPE DATE DATE (Month/Day
CAPE PENTAGON BULK KIRIVATI 76055 8021608 1982 PILIS 4 16466 TME 07-05-2010 01-02-2011 8 MONTH
SANTA CARRIER TIC STROKE 26 DAYS
ALEGRIA

AGOL BIBBY GAS MAJURO 19999 3657 1980 SULZ 2 13000 4TH 10-1-13 7-8-13 6MONTH
CARRIER ER STROKE ENG. 26 DAYS

GAS BIBBY GAS MARSHAL 6107 9013696 1986 WART 4 7379 4TH 8-11-13 13-2-14 3 MONTHS
FORTUNE CARRIER CILLA STROKE ENG 6 DAYS

M.T.KEIL BIBBY OIL SINGAPOR 1871 396409 2009 HYUN 4 3550 4TH 22-4-14 23-10-14 6 MONTHS
TANKER E DAI STROKE ENG 12 DAYS

MT BIBBY OIL SINGAPOR 1871 5147 2009 HYUN 4 3550 3RD 14-12-2014 5-6-2015 5 MONTHS
MUMBAI TANKER E DAI STROKE ENG 23 DAYS

AGOL BIBBY GAS MAJURO 19999 3657 1980 SULZ 2 13000 3RD 1-7-15 6-1-16 6 MONTHS
CARRIER ER STROKE ENG 7 DAYS

SAHARA V SHIP GAS MAJURO 25097 7233 2017 MAN 2 10541 3RD 12/3/17 30/4/17 1 MONTH
GAS CARRIER BMW STROKE ENG 18 DAYS
10 SELECTION CRITERIA MATRIX- IN MONTHS AS PER CDC STAMPED- ONLY FOR OFFICER
(Please give a full record starting with the last vessel on which you served)

VESSEL MST CO 2O 3O DECK CE 2E 3E 4E ENGINE

TYPE CADET CADET
CHEM TANKER
OIL TANKER
PROD TANKER
LPG
LNG
BULK
CONTAINER
OTHERS

TOTAL NO.
MONTHS

# Please ensure that the full name and address of your immediate past employer is entered in section 13 and 14
11 Medical history
Have you ever signed off a ship due to medical reasons? NO
Have you undergone any operation in the past? NO
Have you consulted a doctor during the last 12 months for an illness/accident? NO
Do you have any health or disability problems now? NO

(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)

12 General
Have you ever been the subject of a court of inquiry or involved in a maritime accident? NO
Have you ever had a professional license suspended or revoked? NO

(If YES, please give full details and attach a separate page if necessary)

13 References (Please give the name and address of your current or immediate past employer)
Name of company
Name of person to contact
Address

No.

14 References (Please list two contactable referees or past employers in addition to Section 13)
Name of company
Name of person to contact
Address

No.

15 Automatic review
If immediate employment is not available do you wish to be considered for future vacancies?
If YES, please give any alternative contact details not shown in Section 2

16 Declaration
I hereby declare that the above particulars are true and authorize you to contact the referees listed above.

Date:
Signature