NOS SHIP MANAGEMENT PVT. LTD.
APPLICATION FORM / PERSONAL DATA UPDATE FORM
APPLIED TO OFFICE IN CITY / COUNTRY :.
PRESENT RANK DATE OF APPLICATION
RANK APPLIED DATE OF AVAILABILITY
1. PERSONAL DETAILS SURNAME FIRST NAME MIDDLE NAME
NAME
Date of Birth Place of Birth Nationality
Permanent Address: Present Address:
City & Pin Code : City & Pin Code :
Telephone : Telephone :
E-mail 1 : E-mail 2 :
Nearest Domestic Airport : Nearest International Airport::
2. NEXT OF KIN / FAMILY PARTICULARS
NAME / RELATION :
ADDRESS :
NAME D.O.B. PP/NO. ISSUED / VALIDITY
WIFE S
CHILD (M/F)
CHILD (M/F)
CHILD (M/F)
CHILD (M/F)
3. PASSPORT DETAILS
NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY
PASSPORT
US C1/D VISA
ECNR YELLOW FEVER
4. CONTINUOUS DISCHARGE CERTIFICATE (S)
CDC NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY
INDIAN
LIBERIAN
OTHERS
5. ACADEMIC QUALIFICATIONS Grade/Degree From (Year) To (Year)
SCHOOL
COLLEGE
PRESEA TRAINING
6. LICENCE / CERTIFICATES OF COMPETENCY
REVISION : 1
Issuing Grade Number Date of issue Date of Date STCW 95
authority Expiry Revalidation YES NO
INDIAN
UK / AUS
LIBERIAN
SINGAPORE
OTHERS
7. STCW AND OTHER CERTIFICATES
STCW Courses Certificate No Date of Date of Place of Issuing
Issue Expiry Issue Authority/
INSTITUTE
PSSR
EFA / MFA / MEDICARE
PST / PSCRB (Survival)
FP & FF / AFF (Fire Fighting)
ROC
ARPA
GMDSS
GMDSS END
REFRESHER & UPDATING
RANSCO / NARAS
SMS / NAV CONTROL
INDOS NO.
WATCHKEEPING
CERTIFICATE FOR RATINGS
CERTIFICATE REVAL.
COURSE
SIMULATOR TRAINING
ENGINE SIMULATOR
BTM
ECDIS
ICE NAVIGATION
BRM / ERM / VRM
LARGE VESSEL HANDLING
SIMULATOR COURSE
TANKER COURSES
TASCO / TANK FAM
CHEMCO / CHEM FAM
GASCO / GAS FAM
DCE PETROLEUM
DCE CHEMICAL
DCE GAS
LIQUID CARGO SIM
Crude Oil Washing Course
OTHER COURSES
ISPS (SSO)
HAZMAT
SOC
COOKERY COURSE
WELDING 2G,3G,6G
REVISION : 1
8. REFERENCES (Please give two references/companies whom we can ask about your seagoing experience)
Name Company/Designation Telephone/Contact NO.
1
2
REMARKS:
8A. REF. CHECK YES / NO
9. HOW DID YOU COME TO KNOW ABOUT US? (Please tick the appropriate medium) √
Company
A presentation/seminar B Marine Club notice-board C Marine magazine advertisement
D Newspaper advertisement E Told by seagoing friend (s) F Direct Mail from Company
G Others (Please specify)
10. PERSONAL DETAILS
Height : cm Weight : Kgs
Color of eyes: Color of Hair :
Any major illness / Surgery : YES / NO (If “YES”, Kindly provide details separately)
REVISION : 1
11. SEA EXPERIENCE: (Most recent at bottom)
VE
COMPANY SSEL MAIN ENGINE PERIOD REASON FOR
NAME TYPE DWT GRT YEAR BUILD RANK MAKE MODEL BHP UMS FROM TO M/D SIGN - OFF
Special Experience:
REVISION : 1
12. DECLARATION
I declare that the information given by me in filling up this form to the best of my knowledge are true
complete. I also declare that the documents submitted to NOS SHIPMANAGEMENT PVT. LTD. Are genuine,
given and signed by the persons whose names appear on them. Any false declaration may render me liable
for termination or dismissal
Date : _____ SIGNATURE OF APPLICANT : ______________________
13. SPACE FOR OFFICIAL USE
Assessment : Grade Application Status : Date :
Personality Forwarded to NOS Singapore
Attitude NOS SINGAPORE'S ACCEPTANCE DETAILS
Technical Knowledge ACCEPTED YES NO
English Knowledge REF.
Overall Assessment
Grade: A = Very Good, B += Good, B = Satisfactory, C = Average, D = Below Average
Interviewed by __________ Date : _________
INTERVIEWER’S REMARK:
REVISION: 1
