Synergy Maritime Recruitment Services Pvt. Ltd.

,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

Present Rank : SECOND OFFICER Rank Applied for : SECOND OFFICER

Surname : Tel No. 6383411834

Name MOHANA RANGESH MURTHY Alternate Tel 94,880,144,529,443,600,000

Email ID Skype ID White background. 80%

Date Of Birth (DD/MM/YYYY) Place of Birth : Face

Nationality : Marital Status :

Date of Availability : Boiler Suit Size :

Height(cms) Weight(kgs) Blood Group Shoe Size :

Address :

Nearest Airport
PAN No for
AADHAR for Indian Indian MUI/NUSI or any other
Nationality Nationality Union Membership No

English Language Proficiency : Speak Good Read Good Write Good

Documents Number Place of Issue Date of Issue Date of Expiry

Passport

National CDC
Biometric SID

U.S. Visa C1/D

Schengen Visa

Documents Grade/ Number Issuing Authority Date of Issue Date of Expiry

Level
National Certificate of
Competency (COC)
CoE - Panama

CoE - Marshall

CoE - Singapore

CDC - Marshall Islands

CDC - Panama

CDC - Liberia

INDoS No

STCW Certificates Number Name of MTI Date of Issue Date of Expiry

PSSR

PSCRB

PST

AFF/ FPFF

EFA/ MFA/ Medicare

SSO/STSDSD

High Voltage Training

National Endorsements Number Issuing Authority Date of Issue Date of Expiry

(Where applicable)

GMDSS

Basic/Adv Oil
Endorsement
Basic/Adv Chemical
Endorsement
Basic/Adv Gas
Endorsement
Navigation & Main Date of Expiry
Engine Training Number Name of MTI Date of Issue (Where applicable)
BTM
ECDIS - Generic
ECDIS - Type Specific I
ECDIS - Type Specific II
ME Engine
RT Flex

Ed 01 Rev No 0
FORM : M 01 Page 1 Of 2
Date:10-Jan-2020
 Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

Any Value Added Course /

Company Specific Course
Academic Background
Qualification Name of Institution Board / University Date of Passing Grade /
Percentage
10th Std (SSLC) /Equivalent
12th Std (Hr. Sec) / Equivalent
Pre Sea Training
Any other Qualification
Family Details - all dependant

No. Name Relation D.O.B Sex Passport No Place of Issue Date of Issue Date of Expiry

1
2
3
Previous Sea Experience (All Sea Service details from Cadets/Jr level. List recent vessel first)
Deck (Trade & DWT) Period Dates
Engine (Type & BHP) Type of
Vessel's Name Vessel/Flag Company's Name Rank
TEU (Containers) From To Months/Days Reason for S/off

Last Employer name PIC & Contact No / Email ID:

If yes, Candidate to submit self-declaration background security check
Break in sea service of more than 12 months from last sign off Yes / No
Form M02 at the time of Evaluation
Summary of Sea going Experience
For all Officers: Period served on (yy/mm)
BULK CNTR OIL TNKR CHEMICAL GAS

Handymax Panamax Capsize Centre- Feeder Ctnr >8000 Ctnr >14000 Prod. Tanker Aframax VLCC OIL& Chem Parcel Gas

For Engineer Officers only : Period served on (yy / mm)

Sulzer B&W MAN Pielstick UEC Doxford Steam UMS CPP Cranes MAK / 4-Stroke ME B/C

Pump Experience (in months) for All Tanker Seafarers

FRAMO COP

If Yes, in
Have you been on board vessels during: Drydocking Yes / No which Rank
New
Construction Yes / No If Yes, in which
Rank

Have you been involved in any Incidents of Grounding / Fire / Explosion / Collision / Abandon Ship / Rescue / Major
oil Pollution / Drug Smuggling / Towed or Towing another vessel. If yes, please specify

Have you been involved in a court of Enquiry for a Maritime accident ? If yes, please specify

Have you ever been involved in a criminal case : If yes on any of the above , give details:

Has your present or previous certificate ever been suspended / revoked ? If yes, give details:

Do you suffer or have suffered from : Diabetes / High Blood Pressure / Hepatitis / Epilepsy / Nervous Disorders/
Disturbed Vision Or Hearing / Vertigo If yes, give details :
Are you a habitual user of Drugs / Narcotics / Excessive Alcohol. If yes, give details:
Have you previously worked with multinational workforce? If Yes, What nationalities:

Declaration by the Applicant:

I understand that a strict medical examination including Drug and Alcohol test as per company requirements is a condition of my employment and I express my willingness to be
examined.
I undertake to provide the company’s medical officer full details of my previous medical history. I agree that the decision of the company medical officer is final.
I declare that there are no criminal/ police investigations in progress against me.
I confirm that all my travel documents are valid and in order. I understand that if my travel Documents become invalid or restricted at any time during the course of my employment
and cannot be revalidated by me under normal process, the contract of employment will terminate and all costs of repatriation will be borne by me.
I am /am not presently employed elsewhere.
I am aware that Synergy Maritime Recruitment Services Pvt Ltd., does not have any agents in India for employing Seafarers.
If my application is successful, I will be available to report at your office on or after:________________

If this application sent through candidate's email id, applicant's signature is not required. Candidate should submit the signed application form during the evaluation process/PJF

Name Of Applicant Date Signature of the Applicant

Ed 01 Rev No 0
FORM : M 01 Page 2 Of 2
Date:10-Jan-2020