GRSM MANAGEMENT SYSTEM
Application Form
[PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM]
Individual’s Code Number
1. Personal Data
First Name Middle Name (s) Last Name / Surname
Muhammad Tashfeen
AFFIX YOUR
Nationality (or current Country of Origin Date of Birth: Place / City of Birth:Karachi RECENT
Citizenship ) 20/1/1987 PASSPORT SIZE
Pakistani Pakistan PHOTOGRAPH
(DD / MM / YY)
HERE
Marital Status1: Gender :Male yes Religion: Islam
Single Female
1
Select from : ●Single ●Married ●Divorced ●Common Law Partner ●Widowed ●Separated
Rank applied for: Willing to accept lower rank? Yes Available From (date): ___ / ___ / __
3rd engenieer No (DD / MM / YY)
Primary / Permanent Address: Alternative / Temporary Address: Until: ____ / ____ / ___
Flat No G-1,Adeel Plaza,Block-H,North
Nazimabad,Karachi,Sindh,Pakistan
City: Karachi Post Code: City: Post Code:
State:Pakistan Country :Pakistan State: Country:
Nearest Airport : Jinnah
Home Tel: Phone:
Terminal
Mobile Tel.
Fax: Email:
03002556584
Contact Method : 03002556584 Email Fax Mobile Phone Home Phone
Post
Collar: cm Chest: cm Waist: cm Inside Leg: cm Cap: cm
Specify size as S, M, L, XL, XXL for : Sweater size: Boilersuit size: Shoe Size: 43
2. Personal ID / Documents / Visa
Page 1 of 1 CRW13 – Application Form
File Ref: Office File – 11B Revision Number: 1.0
Type of Document / ID 1 Country of Issue No. Date of Issue Issued at (Place) Valid Until
(DD / MM / YY) (DD / MM / YY)
Seaman’s Book (National) Pakistan 009124-S 22-4-2019 Karachi 21-4-2029
Passport Pakistan AA7844762 26.02.2014 Karachi 25.02.2024
US Visa C1/D
National Seaman ID
Yellow fever
Australia MCV
GIVE TAX INFORMATION BELOW ONLY IF REQUESTED TO DO SO
Social Security Personal Tax
Number: Issuing Country Number: Issuing Country:
Nominee / Next of Kin & Family Details
Full Name of Nominee for compensation in case of fatality: Relationship1 Gender : Male
Nationality :
_______________________________ ________ Female
Address:
City: Post Code: Country:
Email: Tel: Mobile:
1
Select From : ●Spouse ●Partner ●Child ●Parent ●Grand Parent ●Other Relative (Please Specify)
Family Data:
Relationship First Name Last Name Date of Birth Passport No. Issued Place Valid Until
Spouse / Partner2
Child M F
Child M F
Child M F
Child M F
Child M F
Indicate type of valid visa3 USA Canada Brazil Schengen UK Other
2 3
Strike out inapplicable item Please consider period on board
3. STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications: -
(Add separate sheet if data exceeds space available.)
Date of Date of
Description of Cert / Country of Issue Expiry Place of Issuing Authority /
Number
Course Issue (DD-MM- (DD-MM- Issue Body
YY) YY)
(A) Reg I
Personal Training Record Reg I/14
Medical Fitness Cert Reg I/9
(B) Reg VI / 1 – Basic Safety Training
Pakistan PST- 09-03-2019 LEGITIMATE KARACHI
Personal Survival Techniques
2132/2019
EFA- 06-03-2019
Elementary First Aid 0127/2019
FPFF- LEGITIMATE KARACHI
Fire Fighting & Fire Prevention 4128/2019 13-03-2019
PSSR- 16-03-2019
Personal Safety & Social Resp.
6131/2019
(C) Reg VI / 2 –4 Additional Training
ALS 18.02.2021
Proficiency in Survival Craft & Rescue Boat
C-17/CH-
Fast Rescue Boats
ALS KARACHI
Advanced Fire Fighting C-13/CH- 19-02-2019 LEGITIMAT
470
ALS 26.02.2021
Medical First Aid C-16/CH-
468
ALS 26.02.2021
Medical Care (Master / C/O) C-16/CH-
468
1
Select as applicable: ●Passport ●Seamans Book ●Seaman Passport ●Seafarers’ Identity Document ●Registration Book ●National ID Card ●PAG-IBIG
Housing Insurance ●Health Insurance ●Overseas Emp Cert ●PHL Card ●Pension Fund ●Provident Trust ●Professional Organisation ●Driving Licence ●Visa
●Vaccination ●Yellow Fever.
(D) Reg II / 1-4, III / 1-4 Officers Certificate of Competency & Ratings Watch-keeping Certificate (including flag
state endorsements)
4
4
Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you
(E) Other mandatory/recommended Certificates / Courses – (as applicable)
ARPA (Reg II/1 + Solas)
Radar Simulator
English Language
Bridge Team / Resource Mgmnt
Hazmat (US – 49CFR)
Shiphandling /ShipManoeuvring
Simulator
Shipboard Security Officer
ECDIS
Date of Date of
Description of Cert / Country of Issue Expiry Place of Issuing Authority /
Number
Course Issue (DD-MM- (DD-MM- Issue Body
YY) YY)
(F) GMDSS Certificates (including flag state endorsements)
GMDSS (Main Issuing Authority)
GMDSS (Flag State)
GMDSS (Flag State)
GMDSS (Flag State)
GMDSS (Flag State)
GMDSS (Flag State)
(G) Reg V / 1 – Special Requirement for Tankers
Level1:Asst Country Date of Date of Place of Issuing
Description Number Issue Expiry Authority /
Level2:Incharge of Issue Issue
(DD-MM- (DD-MM- Body
Endorsement – Oil
Endorsement – Chem I/II
Endorsement – Chem III
Endorsement – Gas
Tanker Familiarisation (Oil) Para 1
Tanker Familiarisation (Chemical) Para 1
Tanker Familiarisation (Gas) Para 1
Special Tanker Safety (Oil) Para 2
Special Tanker Safety (Chemical) Para 2
Special Tanker Safety (Gas) Para 2
(H) V/2 and V/3 – Special requirement for Passenger / Ro-Ro Passenger Vessels
Vsl Type - Country of Date of Place of Issuing Authority /
Description Pax / Number Issue
Issue Issue Body
Crowd Management RoRoPax (DD-MM-
Crisis Mgmnt & Human Behaviour
Pax Safety, Cargo Safety & Hull Integrity RoPax
Pax Safety
Familiarisation Training
Safety Training
5. Sea Experience : (Last 5 years; Start the listing below with the most recent experience)
Date
Date To
Company Flag & Vessel Name Type (1)
GRT DWT Main Engine (2)
BHP Rank From
dd/mm/yy
dd/mm/yy
AL SALMI SHIPPIMG Al Salmi 1 – NIGATA
RORO 40000 12889 04--01- 04.10.2010
SHIPPING (Dubai) 12 D/M
2010
EITHAD Molly (Dubai0r Chemical MAK 8 4500 4th 07.05.2018 11.12.2018
SHIPPING tanker 18600 cylinder eng
Man
MT Prime 4th
SYRUS MARINE Chemical 23898 B&W 6033 10.01.2019 17.09.2019
Royal eng
tanker 6S35 MC
(Dubai)
SAFE SEA MT Arihant Chemical NIGATA 8
3rd 4400 25.09.2019 17.03.2020
(South Tanker 25000 Cylinder
eng
Africa)
3rd
NAN LIAN MALIHA Chemical Mitsubishi 3000 31-12-2021 27-6-2022
12000 eng
DAMAS
Chemical man B&W 3rd
SHIP MT damas 56000 7643 07.11.2020 21.07.2021
Tanker 6s50mc eng
(Dubai)
SAFE Chemical
MAHAVIR MAN B&W 3rd eng 5180
SEA Tanker 03.10.2022 25.03.2023
35mc
(1)
Use only the following abbreviations for vsl types:
B/C Bulk Carrier FPSO FloatgProdStorOffldg MLP Multi-purpose PAS Passenger Ship YAT Yacht
CON Cellular Container GCD General Cargo MSV MultiServiceVessel RFG Reefer Vessel TNB Tanker(Bitumen)
CHM Chem Carrier IMO I-II HLV Heavy Lift Vsl NVL Naval Ship R/R Ro/Ro Carrier TNC Tanker(Crude)
CH3 Chem Carrier IMO III LSH Lash RIG OffShore Oil Rig PRR RoRo-Pax TNP Tanker(Products)
DRG Dredgers LIV Live Stock Carrier OSV OffShore Supply Vsl SAL Sailing Vsl TNS Tanker(Storage)
DP Dynamic Positioning LNG LNG Carrier OBO Ore/Bulk/OilCarrier SRV Survey Vessel TNV Tanker(VLCC/ULCC
FSH Fishing Vsl LOG Log/Timber O/O Ore/OilCarrier SUL Self-Unloader
FSO FloatingStorageOffldg LPG LPG Carrier OTH Other TUG Tug
(2)
Engineers to give make/model of engines, e.g. “MAN 14V52/55A” or “SULZER 5RTA58”
6. Medical History:
Sheet 4
All previous illnesses other than minor afflictions should be stated below or updated. If not previously disclosed,
the Company is entitled to refuse any reimbursement of medical costs, claim for treatment or for any other insured
benefits.
(A) Have you ever signed off a ship due to medical reasons? Yes No Blood Type:
If yes, please provide following details (If space is insufficient, attach additional sheets) :
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 disability Present condition
(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?
Details of illness / accident Date Therapy/Treatment
(D) Please give details of any health or disability problem
Details:
7. Bank Details: Other Details: (if any)
Bank Name
Address
Account Name
Account No.
Sort Code
8. 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) Give details below of 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 facts and information are true and accurate. I further consent to the holding and processing by (i) the owners of any vessel on which I may be assigned
from time to time and (ii) the Managers and any direct or indirect parent or subsidiary or associated or affiliated company of the Managers (together referred to as "the Companies") for
the purposes of my employment, of personal data about me contained herein, or provided to any of the Companies at a later date, including with respect to personal and pensions
administration, employee management and as required to comply with any laws, regulations or contracts applicable to any of the Companies or their businesses. I understand that this
data will be stored in the Managers’ database for the purposes of my current or future employment arranged by the Managers. Further, I confirm that the above may involve the transfer
of my personal data within the Managers’ organisation.
Place: ………………………… Date: …………………………….. Signature: .…………………………………………………………..
FOR OFFICE USE:
