OPS/101

Rev. No. 6.1

17 Jun 2019
Formerly Known as: Mitsui O.S.K. Lines Maritime (India) Pvt. Ltd. Page 1 of 4
REGISTERED OFFI CE: UNIT NO. 52, 5TH FLOOR, KALPATARU SQUARE, KONDI VITA LANE, OFF. ANDHERI KURLA ROAD,
ANDHERI (EAST), MUMBAI 400 059 l TEL.: (022) 6150 7000 l FAX: (022) 6696 08 88 / 2825 4820
BRANCH OFFICE (Kolkata): BRANCH OFFICE (Chennai):
VASUNDHARA BLDG., SPACE NO. 8, 5TH FLOOR, NO. 202, 2ND FLOOR, CAPITAL TOWERS, 180
2/7, SARAT BOSE ROAD, KOLKATA 700 020 KODAMBAKKAM HIGH ROAD, NUNGAMBAKKAM, CHENNAI – 600034.
TEL: (033) 4003 3700/ 701/702/704 l FAX: (033) 4003 3715 TEL. : (044) 4292 9300 l Fax: (044) 4292 9301
BRANCH OFFICE (New Del hi ): 1301 – 1303, 13TH FLOOR, DEVIKA TOWER, 6, NEHRU PLACE, NEW DELHI – 110 019.
Tel: 91-11- 41677766 / 4167 7788 / 011 2648 1127 l Fax: 91-11- 4167 7799

Ema il: apply@m olmi.com l We bs ite : http://molmi.info/

How did you come to know about MOL / MOLMI ? FAMILY

APPLICATION FORM PHOTOGRAPH

Dear Sirs,

I hereby apply for the post of ORDINARY SEAMEN and am ready to join from 5/Jul/21
I enclose herewith copies of all licenses, certificates and courses that I have completed.
Last name: GUPTA First name: HITESH Other names:
Birth Date : 4-May-89 Birth Place : KHAIRNE Nationality: INDIAN

Marital Status: MARRIED Wedding Date: 7-May-21

Height: 172 cm Weight : 85 kg Collar: cm Chest: cm
Waist: 36 cm Shoes: 8 Eyes: BLACK Hair: BLACK
Colour Colour

Country Number Date Issued Valid till Place Issued

Passport INDIAN P2700145 20-Jun-16 19-Jun-26
USA C1/D Visa
Seaman Book INDIAN MUM186595 14-Jun-14 13-Jun-24
Seaman Book
Have you ever been rejected for any visa applied for (YES/NO) : NO

Yellow Fever Vaccination (Date & Place) : 26/05/2009 & MUMBAI (Lamination not accepted)

Permanent Address: Present Address:

SAME AS ABOVE CASA CLARA B-302, DOWNTOWN, PALAVA-2

DOMBIVLI EAST, TALOJA BY PASS ROAD GTENO:4

Pin: Pin: 421204

Tel/Mobile: Tel/Mobile: 9321585321

E-Mail : h.hitesh89@gmail.com Skype ID:
Ne xt of K in : (Plea se enter wi fe 's name i f marri ed)
Name : BOBY GUPTA Relationship: WIFE

Address : SAME AS ABOVE

Pin:
Tel/Mobile: E-Mail :
Family Details:
Name Birth Date Birth Place P.P. No. Date Issued Place Issued Expiry
Wife: 9/6/1993 ASSAM
Children: Sex

1
2

RECRUITMENT & PLACEMENT SERVICE LICENCE NO.: RPSL-MUM-064 VALID UNTIL 18.12.2021
 OPS/101
Rev. No. 6.1
17 Jun 2019
Academic / Marine / Engineering Qualification and School / College attended : Page 2 of 4

Degree,
Name of School / College/ Date Attended Percentage of
Diploma or
Pre-Sea Training Institute/ Address Marks
Certificate
Engineering College Obtained
From To Received

R.F.NAIK SCHOOL KOPER KHAIRANE NAVI MUMBAI 20-03-2004 25-07-2005 YES 60

ICLES MOTILAL VASHI, SEC:9,PLOT NO.53, NAVI MUMBAI 29-02-2007 30-06-2008 YES 50
JHUNJHUNWALA COLLEGE PIN -400703

Maritime Licences now Held:

Certificate of Competency Issuing Country Number Date passed Date issued Place Issued Valid Until
Master / Class I
Chief Mate / Class II
2nd Mate / Class IV
ETO / any other _______

List of STCW / Other Courses completed: INDoS No.: 09HL1130

Courses Certificate No. Date Issued Place Issued Expiry Date

PST (As per STCW 2010) 2010016112212777 2-Jul-21 mumbai
PSCRB (As per STCW 2010) BPMA/PSCRB-RF/1466/2018 6-Jun-18 mumbai
AFF / FPFF (As per STCW 2010) FR6381 8-Oct-16 mumbai
MEDICARE / MFA / EFA (As per STCW 2010) E8589 22-Oct-16 mumbai
PSSR (As per STCW 2010) R8254 19-Oct-16 mumbai
SSO / STSDSD (As per STCW 2010) ST2812 24/102016 mumbai
REFRESH & UPDATING TRNG. (As per STCW 2010)

GMDSS - NATIONAL
ISSUED BY _________________ (COUNTRY)

GMDSS ENDORSEMENT (IF GMDSS IS INDIAN)

ECDIS GENERIC (Approved by National Administration)
ROC (As per STCW 95 / 2010)
ARPA (As per STCW 95 / 2010)
RANSCO / RADAR SIMULATOR
SHIP MANOEUVRING & BRIDGE TEAMWORK
HIGH VOLTAGE (Approved by National Administration)
HIGH VOLTAGE (LIMITATION DELETED)
SHIP HANDLING SIMULATOR
GAS TANKER FAM. / SAFETY (As per STCW 95 / 2010) BPMA/LGT/449/2018 15-Jun-18 mumbai
- DCE FOR GAS TANKER (As per STCW 95 / 2010) CMMI/GAS/18/39348 17-Oct-18 mumbai
WATCHKEEPING CERT. (DECK - II/4 / ENGINE - III/4) CMMI/WK/NAV/18/6547 20-Aug-18 mumbai
COP - ABLE SEAFARER (DECK - II/5 / ENGINE - III/5)
COC AS COOK (MLC 2006)
SEAFARER PROFILE REGISTRATION 09HL1130

Previous company SHIPPING CORPORATION OF INDIA Contact Person: MAHIPAL SING Tel.No.: 022-22026666
Have you experienced any major damage/grounding/court case ? Yes / No If yes, give details :
NO

Did you suffer any accident which rendered you partially disabled? Yes / No If yes, give details :
NO
 OPS/101
Rev. No. 6.1
Please start from last vessel first. 17 Jun 2019
Sea Service Record :
Please enter number of containers / cars loaded etc. in Vessel Particulars column Page 3 of 4
Vsl's Particulars S/On S/Off
No. of
Manning Owner Crew GRT BHP Date Date Remarks
Year cars/cont/HL Tonnage, Type Period
Type of Agent Operator etc
Name of Vessel Flag of Rank on
Vessel Nation- Type of M/E
Built A/E DD-MMM-YY board Early S/off
Company Manager ality DWT KW Make, Model, Cyl, Bore reason etc.
(Pls use "-" separator)
Dia, UMS/non-UMS
S.S.RAAHI LNG SHIPPING SHIPPING INDIAN 81,237
2004 MALTA CORPORATI CORPORATIO OS 5-Jul-20 20-Mar-21 #VALUE!
ON OF INDIA N OF INDIA 94,058

MV VISHVA PREETI BULK SHIPPING SHIPPING INDIAN 44,007

CARRIER 2012 INDIAN CORPORATI CORPORATIO OS 12-Dec-18 18-Oct-19 #VALUE!
ON OF INDIA N OF INDIA 80,250

MV TAN BINH127 GENERAL CASABLANC CASABLANCA MIX 9,235

CARGO PANAM A SHIPPING SHIPPING CREW
2001 OS 6-Jun-17 4-May-18 #VALUE!
A 11,910

Office to verify vessel's particulars with CDC and Website.

Date : 4-Jul-21 Place : MUMBAI Signature : HITESH GUPTA

 OPS/101
Rev. No. 6.1
17 Jun 2019
FOR OFFICE USE ONLY : Page 4 of 4
GENERAL APPERANCE, PHYSICAL ATTRIBUTES, DRESS,
SENSE, MANNERS & ATTITUDE

EDUCATIONAL / PRE-SEA / NAUTICAL / MARINE

ENGINEERING BACK GROUND

PASSPORT ISSUANCE - PERSONAL IDENTITY

VERIFICATION

COMUNICATION SKILLS ACCORDING TO POSITION

(ENGLISH KNOWLEDGE)
EMPLOYMENT RECORD,
REASON FOR LEAVING PREVIOUS
EMPLOYER
SAFETY AWARENESS, KNOWLEDGE OF ISM CODE,
MARPOL, SOLAS, ENVIRONMENTAL PERCEPTION (ISO
14001-EMS, 50001-EnMS)

EXPERIENCE WITH OTHER NATIONALITIES CREW.

CROSS CULTURE KNOWLEDGE

EXPERIENCE WITH VARIOUS PORT STATE CONTROL,

FLAG STATE INSPECTION,RIGHTSHIP INSPECTION,
VETTING INSPECTION.

KNOWLEDGE OF TRADE IN SPECIAL AREAS LIKE WEST

AFRICA, INSPECTION BY PORT AUTHORITY, QUARANTINE
AUTHORITY ETC.

FULLY AUTOMATED ENGINE-ROOM EXPERIENCE

WITHOUT ELECTRICAL OFFICER'S SUPPORT

STEAM POWERED / OTHER SP. AUX. MACH. EXPERIENCE

LIKE BOW THRUSTER, SHAFT GENERATOR ETC.

DRY DOCK / NEW DELIVERY EXPERIENCE

TYPE OF PMS EXPERIENCE

HEALTH CONDITION CONFIRMATION

EXISTING ILLNESS, IF YES, MAINTAINANCE DRUGS

ALCOHOL/SMOKING/TOBACCO HABIT CONFIRMATION

Comments:

Date Name Signature MUM / KOL / CHN / DEL