GOVERMENT OF INDIA

MINISTRY OF SHIPPING
MMD DELHI
Application for GMDSS

Application No. : GMDSS/MMD(DL)/2019/6362

Application Date : 08-APR-2019
Office Applied To MMD DELHI
Personal Details
Name of the Candidate : UTKARSH MATHUR

Date of birth : 05-APR-1992 Place of birth : JAIPUR

Nationality : INDIAN INDOS No. : 10NL3699
Passport No. : Z3858555 CDC No. : MUM 189114
CDC Issue Date : 21-JUN-2011 CDC Issue Place : MUMBAI
Application Details
Place of Examination : MMD DELHI Date of Exmination : 29-OCT-2014
GOC Certificate No. : D-4699 GOC Issue Date : 30-OCT-2014
GOC Valid Till : 29-OCT-2024

GMDSS/MMD(DL)/2019/6362
GMDSS Certificate No. : 0003791
GMDSS Cert. Valid Till : 29-OCT-2019
GMDSS Cert. Issue Date : 05-JUN-2015

Name of the Doctor : DR. RANBIR SINGH DGS Approval No. for : MAH/MUM/63/2015

Place of issue of Date of issue of Medical

: MUMBAI : 13-FEB-2019
Medical Certificate Certificate
Address Details
House No. : 4-E-17 Street : R.C. VYAS COLONY
Village/Post Office : BHILWARA District : BHILWARA
State : RAJASTHAN Pin Code : 311001
Email Address : mathur.drajay@gmail.com Mobile No. : 9413823835
Cert. Receive Mode : By Post

Sea Service Details

Name of Vessel : INDIGO SUN Vesel Type : Oil Tanker

Port of Registry : MONROVIA Rank Served : Watch Keeping Deck Officer OINW or Third officer

From Date : 11-JUN-2018 To Date : 13-DEC-2018

IMO No. : 9592288 Remarks :

Name of Vessel : WHITE MOON Vesel Type : Oil Tanker

Port of Registry : MONROVIA Rank Served : Watch Keeping Deck Officer OINW or Third officer

From Date : 16-SEP-2017 To Date : 23-FEB-2018

IMO No. : 9588158 Remarks :

Name of Vessel : CAPRICORN SUN Vesel Type : Oil Tanker

Port of Registry : MONROVIA Rank Served : Watch Keeping Deck Officer OINW or Third officer

From Date : 12-OCT-2016 To Date : 31-MAR-2017

IMO No. : 9333785 Remarks :

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 Fees Details
Amount (Rs.) : 3000 Payment Mode : ePayment

Payment Date : 08-APR-2019 Reference No : QAXG7417491707

Attached Documents
Sr. No. Documents to be uploaded

1 Scan copy of signed online application

Passport size (3.5 cm X 3.5 cm) photograph with clear white background face covering 70%
2

3 Scanned signature of seafarer

4 Recored of One Year Sea service in Original letter issued by the Vessel Owner / Agent with RPSL No. & e-Mail address

5 Scan copy of Indian GOC(GMDSS) certificate with renewal page(s).

6 Self attested scan copy of Medical Fitness Certificate from DGS Approved Doctor

7 Self attested scanned copy of CDC booklet pages showing relevent sea services.

8 Scan Copy GMDSS Certificate

Declaration
I hereby declare that all the statements made in this application are true and complete to the best of my knowledge and belief and
nothing has been concealed/distorted.

I Agree.
Place : Signature of the Applicant :..................................................
GMDSS/MMD(DL)/2019/6362
...............................
Date : 08-APR-2019 Name of the Applicant : UTKARSH MATHUR

Report generated on : 11/04/2019 3.29 PM Page 2 of 2