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Form 29 Filled

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Subham Samantaray
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Directorate General of Shipping FAC Branch CHECK LIST FOR NCV CLASSIV ASE OF MERCANTILE MARINE DEFARTMERT Talon io Co Scams fr RTE Fa SY CV Wises wa Or aso en ae naar ge Slanted an he Aruna Teflon Sextet “ASSESSMENT FOR WRITTEN EXAMINATION. Tne 'NAME OF DOCUMENTS. YESRO REMARKS aC cig lot pus ofa Cao of Pang nd ae apr oD Cee z ogy of Edson ui So onan of ren Cas Te SOED VED ER Yee Reng Cnn 11 Dpoon a Meshal Eauinesing ical gry eee Siguig Orin of Pe Sex cous Sct Se Sree rue by he Owae oteVor PSL (Altenedto 0.5) Copy Sea Servis Teno Tang Arie Tie Sepa clea Remar (ey red Fag velo Se Fei Exact (On Ny Cua) Sra ats Met Fes Gefen (005 Apart DST Se he FLERE TIL IN 1 CPRTIEICATENO DETAILS Caio | eae aA TREE Vaid win er obese Ti rene Ab a in a 595 7) PSS Reet ese rf $50 or SSO, rpfin Coun oe Tice Avene Fees a appa -TGNATURE OF VERIFYING DA TAPPROWRG AOTIORTY "RAMEOF DOCUMENTS: Fesno [| _ REMAN apy of Wes eon ees Seve Testing Anil Te Cop of Ai feet Only rnin Fag velo DETAILS oo Aes ul fr ina 8 STAND TARE AWAY = PLIAGE FILL ISTE CERTHICRTENO. ane ng Ogial TECW Com 7) [PSCRB OR Reeser ay [are a0 08 iy [esa Fit Ae val wi i] s80.0-S1S050 PSSR Ups OE siLran nook Fens bol Avessne A Baniaion oo Tena vei DA TPROVING ATTTONT Directorate General of Shipping EAC Branch (CHECK LIST FOR NCV CLASS II (SEO) [NAME OF Mercanile Maine Deparment Following Documents Are Requied For NCV Class Hi (SEO) Writen and Oral examination andl ‘Assessment Photo. Copies Of Each Documents Sef Atested Must Be Aranged In The Following Sequence ‘Name OF The Candidate Date WRITTEN EXAMINATION REQUIRE DOCUMENTS YESINO REMARKS py of COC itog elvant pages ose saves Copy of Passport (and last pages) Copy of INDOS Cerificate pertaining to Ennening Caen Copy of NCV Chet IV Cerificate of Competency ‘Orginal See Service leer led bythe Ovmer ofthe Vessel” RPSL (Addressed to PO, MIMD) Copy of Sea Service Testimonial, Indiaing Avice Tine and Propeling Days duly Copy of Ace of Agreement (Only fo Tadlan Flag vase) / Form ‘Copy of Valid Medical Fines Cenifiene (DGS Appavei) Copy of Seafarers Profle (Undated) to be etumed afer verification 101 nt Fes ag applicable — evidence u. DOCUMENTS To BE SHOWS AND TAISEN AWAY PLEASE FIL INTTIEGH ‘Original ofthe STCW Course a follows o be shown ‘Cen. No RETNA Taste {| PSCR Valid within 5 yearsor Refresher Ti. __[ AFF Valid within 5 yeas or Refresher SSR Updated wo 2010 ‘Original of Medial First Aid valid within st 5 years 'y. [$80 or STSDSD Signature EDA ‘Signature ofthe Approving Autry. ‘ORAL ASSESSMENT Fees: as applicable ~ evidence of fos paid 13, Sea tne assessed tase on he dovamentssubiied above 14 iting oF Origa of Preparatory Course 1s. igng of Result of Ween Examination Tigueare of he Candie Date Sigua ofthe DA Date Directorate General of Shipping EAC Branch ‘Check list for NCV CLASS III (CEO) [NAME OF Mercaille Marine Department Following Documents Ave Roqked For NCW Chss I (CBO) Writen and Ora examination and Assesment Photo. Copies Of Each Documents Seif Attested Must Be Aranged In The Following Sequence ‘Name OF The Candidate Date: WRITTEN EXAMINATION REQUIRE DOCUMENTS YESINO REMARKS Copy of COC icing relevant pager of sn servic [Copy of Passport (1 and las pages) [Copy of NCV Clas Il (SEO) Cenifiae of C T 2 3. | Copy of INDOS Cerin peraning to Engineering Categon. 4 5 ‘Original Sea Service leer sed bythe Over ofthe Vessel7 RPSL (Addressed to PO, MMD) Cony of Sea Service Testimonials ndealing Ave Te and Proplling Days daly Copy of Article of Agreement (Only or Indian Flag vases) 7 Far Copy of Seafarers Profle (Updated) ro be retumed afer verification c 7. 3. | Copy of Vala Media Fitness Conieate (DGS Approved) 9% 1 iO] Assesment Fees applicable = evidence NTS 10 BE SHOWS AND, Porase ELT sTIICATE ATTEN. 11, | Oxsina ofthe STCW Course a follows w be shown No 7 PSCRB Valid within 5 years or Refesher [AFF Valid within 5 years or Refesber SSR Updated to 2010 iv Original of Medical Fist Aid valid within at § yeas ‘v, [$80 or STSDSD Signature ofthe DA ‘Signature of the Approving Auboriy ‘ORAL ASSESSMENT. = pplicale evidence of ees paid ‘ea time assessed based onthe documents submited above Tighing of Orgad of Preparaiony Course 14 Sighting of Rest of Wren Examination 1s, Signature ofthe Candidate er Signature ofthe DA Date Directorate General of Shipping EAC Branch (CHECK LIST FOR MEO CLASS IV_ WANE OF MERCANTILE MARINE. DEPARTMENT o lng Doarens Ae Roque o be siblad Fr NEO CLASS TV Pat A Exenpon& Pan BEX aston [os Anesment Requzences ows Cop OfFach Docent austbe Self Anewed aed Arango The Following Somenee ‘Nate Of The Candidate: Date: FART A EXEMPTION © ERANTRATION. ao. THAME OF DOCUMENTS YESRO [RENAME T | Cag CDC Cat a) wd leat ein ge 2 apy apne Lat Pag) 5. apy of NOS 5. Criene 7 [ ene offers Pid z Cayo Eaton oie ESTEE Gop of Fe Sx cue 7 egy of Va vote Fane Oia [DUS Approved Dos) SNo Details of dacements| ERENO paar ors 1) [PevoralSashal Teaco Reiss yao ip [Fae Peet Fre ihng ce Refer i mere ar Seas a [este Ft A wa hy PSS whe Seas ore ~ [sts030 Tira of Voting DE aerrg aay ase on sve inmates tv cndneeammpied rom PARTA 7 EigDeTe spear la pat To] ia Se eres ete sued bye Ont RPSL ares fo Seemed PO 126. vaso | _newanxsir avy a of Sea Save enol Icing Ae Proping Ue 2 Tal Ale of Ament Form fe of COC fcaing lve cage of SN sro NAME OF DOCUMENT ccontvo [umeorssroun | ga of npn Ram Smor Coane Done far rogue alg) 2 | Seg of STOW Cours on 2 FSCRS val whiny ore : Ta Asn i Fghing Val wenn 5 eae i Medi Fint i a tn at in [350.1510 Figaro Cnt DATE ANNEX [Wit GSS DOCUMENTS TO-BE ARRANGED ASPERFOULOWING i Ti Na. Nate ofthe documents required (sel atested copies) 1, [ferm29 (avaiable online on md gov.) tobe duly led an ined as per ached |__* format, ony wit back pen 2 lear (oharathosh /eparitsha)& Part (eparisha compulsory) Payment receipt, [3 feparksha Form [oul ed signed heck 5 |obe (a pages) ‘6 [Passport fa pages] 7 —|o0s- [Al Passing Coens & Mavlaheets of Education quaiation equved 0 i ath i] [Degree (al semester marksheat Iw) [GME as appcabie all pags] [Pre sea course (oth sie) sued by Coleg /nstte 110 |Medical fess shouldbe updated in master checker a3) 1 |Faiowing sTCW courses i PSC PST [i.__—laFF a FPF ju Psa Tw) [MFA [era [wi _—S1S050 jit ens is) [Boer course as appeable Ta [sea Seven Testimonial 33 [form 3A Mast Checker) Si feofarer Profle 35 |Oce certeate(fapplebie) 36 |figh voltage Certicat ( appeaB) ‘7 JTARBOOK (Pre & Onboard] (copies of pages conaing perso information, phat, ltamp, gages stamped towards sang, page no. 22 reviewed by company) TE [Proforma 8 batch approved by Dos Ise declaration stating that the documents subrited are genulne and authent. 33 _|faure any eiscrepency found candidature willbe cancelled 0_|Orginal company sea sevice letter o PO, MO 21 Jor nos. Eta latest photo, 70% face covering, in formal & white badlground 32 [ni documarts re required fe fagin a partie report ie fle ‘ SAMPLE” ee “USE ONeY BLACK POINT PEN” ae “CAPITAL LETTER ONLY? FORM 29 (S00 Rule 72) GOVERNMENT OF INDIA MINISTRY OF SURFACE TRANSPORT. DIRECTORATE GENERAL OF SHIPPING Application for Examination and Assessment for certificates under Merchant ‘Shipping (Standards of Training, Certification and Watch-keeping for Sea“aers) [Rules, 2014 for manning ships in foreign-going and Near-Coustal Voyages trade ‘pplcaion No, + £-funslerhe ID on al! popes Received Date: _|__/20__ A. cradeo mo cL. ES TET PHOTO Examinaten Face ot: MMO_IUPBAT eas] Examination ee as vee easter 4. Ful Name prDy SAAR CoV PTAA {Boocetes) 2 Backgxeumel Laheat vrtt~ TAROWA, PO-- LAURA, PS=nURIA | 2, Permanent Assess | DIST = HAYA, BIHAR- 824905 tec SAME AS ABOVE ‘OR OTHER 4. 4p Number ecrwewtID (wa 1 cosy ¢296¢90317 Sanat oy ‘(Proof to be produced) oie oe "ass yume HOP S25F epeccon Numer: CO! ee 7.Date and Place feswe :_DD/mMMYyYYYY €. Contino Oseharoe Eentens(cO0) | — Nater J mum Bar @.Data ond Pace ctiswe ; Dos mel YYY% ‘1C. Date of Birth of / 1994 (Proof to be produced) ered Puce of (Ae Per Povofor?) E 1&.Personal prolé ON THE LEFT CHEEK ‘Identification marks we 12 NDos No 3 14 EXNAS No, Lifter. neceivigg for rmd) Not: oy Person who mates, cauae 0 be mace rset ning nya apes fo the purpose of car fer mse esate ny abe pun Gia ar bee Pesoaaon arse Secon 18282) fhe aan Penal Ce 80 > S oft Applicaton Ne, : _e:fantoko.TD Received Date = _/_/20_ 8 pera oF scnotasic EDUCATION {Separate sheets must be tac nap [240] Diploma / Degree CAS appli cable ) 1. Schlase Education Level 2. Pincipal Subjects 2. Year of Passing 4 SchoolCooge/ Bead: Nawe of University 5 Asso ho nston ©. DETAILS OF PRE-SEA TRAINING/ MARINE ENGINEERING WORKS} (Separate steetmertbemtacied) Teen, Marine 7 IME (As appltcable) 1. Training Insttite Aeros ofthe Inston 9. Attended From 4. Resut Pass 5, Courses Altensed B.teth Marine | Gime Cos appli ubled D. REQUEST FOR ALLOTMENT OF SEAT FOREXAMINATION: ((Byrnore” clortust) Les! | snaureot | Siatrost Montend pout ate | Recto. |Functon_(Operetanl! | Sepauect | ‘Eran’? — Management) ‘Assessor et 2 aeagee (Reo gad ee ee a » | 2. 000h (oh nol age | ee . REPORT ON STRUCTURED ON-BOARD TRAINING (GMEIATSIOTHERS) Name of Designated Trnng Ofer Pel alas OF CarteteOtComatancy e__ | Bale oF Completion (AMD) Page 2of1 Application No, e-pasilisha ID Received Date: _/__/20_ (Copy of Training nstuttotcer Report tobe Furished ) ‘PHASE 1 As Apprentice Engineer Offcar PHASE 2. As Trainee Engineer Ofcor PHASE 3- As Engineor Offer hela Glass IV COC PHASE 4s Enginee Ofer hang Clas COC F. DETAILS OF SEA-GOING SERVICE (FOR ENGINE DEPARTMENT PERSONNEL) | ibis! | aa 'SSE thE wee. ae? “Beem FA gw ety ame | “0 araleat aol we toate fl] Toll Anco Peed : [— ‘Note: State whether performed LILY, VI |-Ontiters Work, ther by day or on watchs on Deck or in Engine and Bole Rooms: "On regular watch on audits oF retgeraton and a-condtioning machinery. On regular watch - on main engines. 1. On regula wateh - on main ols Y.Onroguar watch -on both main ongnes and bole simuttancousy, VI. On ships. partly oc uly uimanned machinery space, ‘The use of appropriate Roman numbers wil scien for IV. V and * OSS. Qvaiying Sea Service (Propeting Time Caled al 20 Days a Month) "FG (Fordgn-gong), CV (Coastal Voyage) rINS(ndan Naval Service) er CG(Coast Guard) L Page 3.0f11 Application No. e-favieka FD Received Date: _/_120__ G. PARTICULARS OF STCW CONVENTIONS MODULAR COURSES ima Tacos es [PRR ert | vot ean |e ‘reson suavvat ‘ E memset | pa) ia W2l008 181 2pue RETREAT ago t 2 pRERNN amee misieie zalshene lutseevrasramcera | Ue p ‘emia! ip saith estore 7 apace 0 iS SA aio ¥ s97/012018 2ols/e08 Hetlwcrwsumma, = ial 2 ERSTE Lam Ja Yeates tao © Rites rec ner viens seiatens RancAcasra pS [meee cara + trae £ ft + =e re FE sso |S aie YW Page dof Applicaton No.» _€ 2D Received Dato : _/_/20_ Level Ape fr OPERATIONAL MANAGEMENT LEVEL (Tx Maintenance and repair at Operational and Management level , Page 7 12 Application No, farthha sD Received Date: _/_/20_ Bagrenacee eee ee Game Forte Use Only Das Re 08 Fl Conia No LATEST PHOTO. dt A Nameof Candas: BINDU SAUAR CoUPTS 05x35) Pecnanet Adds Are pose Dae o Bien 110111951 Pocot ith: 4s pea Pee bor? Comney: EDTA eam Cor: UMOAT Sie aa na e107 Rosation No, EXN4S No: (Offer Receving Exam Date ae ‘evel Appl for OPERATIONAL / MANAGEMENT ate FUNCTION aes is Ta aR RTF FR VT @ s -_ /35 ano] MEKiSm | MEX | MEX | na | vant | watt | Gonnene | NO) | owas [MET|MEP| -|- Mle ly eA viele lel 8. Witten Funcon Passed OPERATIONAL / MANAGEMENT Level Pots FUNCTION Sign of Examine F 3 [ae Re faa Tea aT we eye — WY Tn [eee EKG] wEx | wex = | Mor | taste e Page @of 1 Application No. efanhihea ID Oras Function Passes OPERATIONAL / MANAGEMENT Level Received Date = _/_/20__ Slonot Date FUNCTION Function Function Function 6 | Fonction concen | medion | metmam | mer on tats of Functions Whiten Papers 3 Contotng the operation ofthe ship and care fx persons endoat at operational nd management level NA.- Naval Architecture, SS and EP- Ship Safety and Enicrmental Protection and Personne care )4A- Part A Marine Engineering 2t Operational level and management lve, MH: Mechanics and Hyéromechancs, .H.T- Thenmodynamic and Heat Yansmission 48 Part Marine Engineering at Operational love and management level Page9oFa ‘Application No. oe favi tha Received Date For MEO CLASS I- LE.K Sim COM) - Marine Engineering Knowledge (Steam) MEK. (G)- Marine Engineering Knowledge (Genera) MEK (N/SISm) -Marina Enginewing Knowledge (Mole) For MEO CLASS -ME, = Engg-Mami- writen 5: Elctica , Electronic & Conta Engineering at Operational and Mariagement ve MELT. Maine Elecro Technology 6 Maintenance and rep at Operational and Management eve MLE. Marine Engheoring ractco Detas of Functions : Oral Papers = COSCPN - Conraling the operation ofthe Ship and Care fr persons on oars |4-ME Matar Marine Engineedng (Moto), ME (Steam Marine Engineering (Steam) 5-MET.- lectiea, eacronic and contl engineering 15: MR. -Mattenance and Repair | Exainer of Engineers Final Assessment Pir Recommendation for Cetiaton io Requremens| Stats Requrements siaus edicalFeness| ‘Yes/No | Preparatory and Up gradation YesiNo Pre Sea Training Yes/No | otners (Sate Course) ves to Structured en Board Training YesiNo | writen Examination Yes/No Sea Service Requirement Yee/No | Oral (Assessment) YesiNo Nodar Courses yesino | Eigtity Yes No For ihe Cut Exar engineer Oicors 4.1 hereby cei that —____bom at. ‘Sea.going Senoataih Reaping Servic. |___ as sattacony produced tosimonials and proof of Sing takeaatecomplcs nt the requrements of he Merchant Shipping (Standard of Training Cerfcation and Wateh- ‘eoping for Setorers) Rules 1008 forthe grade ct 3 The eandidete has passec bis examination for ne Tuncions as under age 100! 12 ‘Under STOW Rage Apsilication No, cfartfha Td Received Date _/_/20_ ancien ‘amination Contre MontiYeur Remarks ‘The ands neds a he Toque By gle hi Rae We C3 Compa ~~ With lowing into. “The cei of cmp maybe farwarded oe Mere Marve eprint fr issuance (Signaure) ‘vain of Engineers Mecunile Marine ten of Competency or pd netcanle rie dpa ay bee thon scorn by [REMARKS (Spit Condon fan) Int of Asse BOS, Deals of Fonstions 3 -Conaling the Option a te Ship & Care fr Pesoson bart Operatic and Mansysnt Le! ‘38- Par 8 Marine Engineering Operational Lee! and Manageme Level Het Eis l= Applied mechanics I - Matemais 1V = Enpoesing Drawing V ~ Mechanics & Hysonchoniss YL Themedypanics nd Heat Tan 4B. Pat B Manne Engineering t Operational Loveland Magen! Level 5-Elerieal, Flcrones Coto Engin at Option! Management eve (6: Manace nd Repair st Optional and Manageneh evel ‘susan. fling up and mis he Fino Regie to DGS (A) On the cant using all cons in a grade and o star evaluat by Examiner of Engines he DGS Fiat exer duly completed must be sn the DUS, Conant freer natn. Aptian Form eed nt esto Dos (B) The shes soul be preesly conpues Gncoted and Recorded (©) A copy ofa shect shold retained athe espetve MND Prior dsthed o DGS ss hard epy Condes Specimen Sipwtues (Toe ly signe nal ou bos tthe time of bison a wh ot fe oe d Cabos DG i ay oT OOE aie ee Page 11 of 11 oa FORM 29 (See Rule 72) GOVERNMENT OF INDIA MINISTRY OF SURFACE TRANSPORT DIRECTORATE GENERAL OF SHIPPING Application for Examination and Assessment for certificates under Merchant Shipping (Standards of Training, Certification and Watch-keeping for Seafarers) Rules, 204 for manning ships in foreign-going and Neat-Coastal Voyages trade ‘Application No. Received Date: A Grade of TATEST PHOTO Examination Place ot MMO. eae Examination 1. Ful Name (Block eter) 2. Permanent Adsress 3 resant Acéoes 4. Telephone Number (wih STO Code) 15, Nationality (Proof toe produces) 6. Passport Number 7. Date and Place of seve £8. Continuous Deenarge enteate (0.6) Number 8 Date and ace of seve 10.0ate of Bit (Prootta be produced) +1.P ce of Bien +2.Personal denttcaton marks 13.1NDoe No 14, EXNA5 No Note: Any Peon who make, cute be made eis in mang any le erearan fe supose ois kx irs bere ny oe person + Crate, sabe tao one nde Schon 1&2 othe ason Pool Cos OE, Page 1of31 Application No Received Date = _/_/20_ 1B DETALS OF SCHOLASTIC EDUCATION : (Separate sheets must be attached) 4. Sonolte Eostion Level 2 Princal Sujets 8 Year o Passing 44 SenodtColege! Board §. Adress ofthe Inston ©. DETAILS OF PRE-SEA TRAINING / MARINE ENGINEERING WORKSHOP "(Separate sheet must be attached ) 1. Training nate 4 Aedes of he instation 5. Attended From 4 Resut ‘6 Courses Atended 1p, REQUEST FOR ALLOTMENT OF SEAT FOR EXAMINATION : Ment Level wer’ Amount Date | Receipt No, Function (Operational Management) E_ REPORT ON STRUCTURED ON-BOARD TRAINING (GME/ATS/OTHERS) | Ox oFcanpiinvnuoy | Name Caged Tra Ost Page 2 oft Sgnatue ot | Signature of Canddae | Gxarine Dette OF Cero OF Competency Application No. Received Date © _/-_/20__ (Copy of Training InsitutelOfier Report tobe Fuishes ) ‘# PHASE 1-As Apprentce Engineer Otcer PHASE 2-As Trainee Engineer Offcer PHASE &_ Ae Enginer ricer oling Claes IV COC PHASE 4 AS Engineer Offer hong Class COC F. DETAILS OF SEA-GOING SERVICE (FOR ENGINE DEPARTMENT PERSONNEL) lls | =o We) - Fle). rts oon 8 Total Anele Peed: [] Taw 088: | Note: State whether perormed LILILIV.V.V |LOn ters Work, ether ty day er on watenes on Deck orn Engine ana Bole Rooms I On equa waten on aulais °refegeation anda condoning machinery. On regular watch - on ain engines. IN. On regular watch -on main boss. . On raguar watch -on ath main engines and bles simultaneously ‘On ships, party ory unmanned machinery space. “Tne use of appropriate Raman numbers wl be sufi fr ll N.V and = USS-vaitying Sea Service (Propeing Lime Caculates a 0 Lays @ Mont) = FG Foren ging), C¥ (Coastal Voyage or INS{Insian Naval Srvc) or CG{Coast Guard) Page 3oft ‘Application No, G. PARTICULARS OF STCW CONVENTIONS MODULAR COURSES: se No Soealtsvnstiras SRbvaNCe RAE rex int ‘grow Rog | Ne ‘proved Instiusion vata ‘Application No. Received Date _/._/20__ H. Level Applied for OPERATIONAL / MANAGEMENT LEVEL (Tick «/ the appropriate Function) SE ae eer emir pore cm cae |. PREVIOUS CERTIFICATE (Isued in naa oretewnere, none stat so) 1 melee ic Pace & dae of Henriette ere examination | tome | ‘one | Cause 4. DECLARATION TO BE MADE BY THE CANDIDATE | hereby detare that he particulars conned in he form are cavect and tue to the best of my knowledge and bebet ‘and that the papers enureated and sont with is fom are re and genue documents given and signed by De person ‘whose name appesrs on hem furher declare thet Secon Feantans aus and correct accout of my sea-gorg sce {winaw exception and make hs decaration conecentousy belowng the same tobe te. | eee ‘The above decsvation was signed in my presence Sioratur of the cancate Examiner of Masters and Mates/Engineers Oars Mercantile Marine Deparment Ditet K POST-SEA APPROVED EDUCATION AND TRAINING AT APPROVED INSTITUTION LEVEL (Preporator, Vecaboral ara Up reason Courses) Page Soft ‘Application No. Received Date» _/_/20__ Remarks Function Pat Inston From To Stating Gragesin | ‘assosement LL REPORT OF HEAD OF ASSESSMENT CENTRE (Preparatory, Vocational & Up gradation Courses) (Candis Peromanca, sven and weakness any mute clay sate here. Report cars destred by ston anda ‘Suntance ws DUS seccves mst be sacha, dear nang paces nevis ofpeormance ahve) Sgnature Name ical stamp: (Soe & ae strate Cte) ‘vty of oe th Ole ard 00S ao im be tanec) 'M, REPORT OF HEAD OF ASSESSMENT IN EXAMINATION SECTION Documents 9 Order Yao Proerma for WiShop Training Checked end Talled — YeuNo Photos Encosed YeaNo TAR Bock duly Completed and Endorses Yea Fees Recewes YeuNo COICEW Book Duly Completed and Endorses YouNo Candidates Egil for Function Grade of Examination assessed and in ender N. EXEMPTION Exeapon any Gite Rae (lm RETA Manual i) Spel DOS relerence) Signature of Examiner of Enginoer pert Chet Carina of engous (©. REMARK OF EXAMINER OF ENGINEERS: ASSESSMENTINORDER _YesiNo ELIGIBILITY FOR OPERATIONAL LEVEL / MANAGEMENT LEVEL EXAMINATION gible For Ween 30 AA 4m AAI AAV AAV AO) 48D 8) oO Elle For OraiFuneien 30) 40 5) 61 Candidate Found Inegible And Duly Informed Yes No (Use Form IN) Signature NAME OFFICIAL STAMP, Page 6 oft Application No. Instructions it alt ine Black ballpoint Pen, Cl 2, Allentries must be made by the Candidate in his own handwriting except those for official use, which are ‘Shaded grey. 5. Grades of Examination (Page 1) MEO (Main Stream) ~ Class TV, Class, Class 1 Nev = Class IV, Cass ill SEO, Clas Ill CEO 4, Candidate mast refer to is EXN-4S and META Manual | & I, t0 assess his own eligibility forthe relevant ‘courses / Exams before filling in this form. 5, Deuils of Name, Date of Birth Ete. must be as per the SSC, HSC, Board of Examination Certificates uniess ‘changed by legal means ‘6. Candidate must produce the originals for verifications at every MMD. Verifieation of Certificate may be resorted to by MMD if required. 7, Two additional Passport Size Photographs with the signature on backside is fo be submitted along with application Form in a stall Envelope for attachment with DOS final register. 8, Sea time certificates must be dual endorsed by either Indian Embassy, Consulate abroad, Flag state officials of flag of vessel or any other organization approved by the Directorate. 9, Entries in F must be made for each pase, giving date of completion asthe date of discharge from ship. Name of ‘taining officers the shipboard or company designated officer. Deus of certificate of competency are the ‘current certificate which the eandidate holds. Attach separate sheets for ational entries. 10. Entries in Part [which includes sections A, B,C, E,F,G, HJ are to be made by the candidates. 11 Entries in Part II which includes sections KL, MN and O are fr official purpose only 12 Entries in Part~ II is exclusively for official purpose only Deuils of Functions 3 ~Contrlling the operation of the ship & care for persons onboard at operational and management level {4A Part A Marine Engineering at Operational level and management level. [= Heat Engines II — Applied mechanics IV — Engincering Drawing V — “Mechanics & Hydromechanies V1 — Thermometer and Heat Transfer. 48 - Part B Marine Engineering at Operational level and management level, 5. = Electrical, Electronies & Contol Engineering at Operational and Management level. 6 ~ Maintnance and repair at Operational and Management level Page 7 oft ‘Application No. Received Date: _/_/20_ at Foroffiee Use Only Das RefNo OS Final Cerin No. TATEST PROTO ane of Cnt me Pease Adres ate of ih: ea Pace of Bi coun xan Cente ‘sue eatin No. EXNASNo sam Due ‘A Level Appl for OPERATIONAL / MANAGEMENT [Senor ate FUNCTION ae a [ERT [ARN RW [aR e se wy on [RoI vow | tar [ERs [EX | MEX elmer o eae | ol | ss £2. Witten Function Pasted OPERATIONAL MANAGEMENT Level aa ancIon ‘Sign of Barer 3a WA aR [AR Yaa A s ss wy er (sexi wex | wee wa mG | ost Page Bet 14 ‘Sign ot ‘Application No. Received Date © _/_/20__ Ovals Function Passed OPERATIONAL / MANAGEMENT Level __ Date FUNCTION Function 3 Function 4 Funcion § | Function 6 cosco | me qian | Memon | wer un Dai of Function Wien Panes '3-Controling the operation ofthe ship an care fr persons onboard at operational and management evel INA - Naval Arctecture, 8S and EP - Ship Safety and Eavienmental Protection and Personnel care |48- Part A Marine Engineering at Operation level and management eve Mt Mechanics and Hydromeehancs, THT -Thermodyeanies and Heat ransmislon 48 Par B Marine Engineering st Operation lvel end management ove, Page oft Application No, Received Date « _/_/20__ For MEO CLASS l- MLE K (Sm COM) - Marine Engineering Knowledge (Steam, MEK (G)- Marne Engineering Knowedge (Gere!) MEK (WSIS) -Marne Engineesng

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