APPLICATION FORM

1 Position
Position applied for: 2/O
Are you willing to accept any other positions? NO
If YES, which positions would you consider?
Are you responding to a media advertisement? NO
If YES, please state which publication
From what date will you be available?

2 Personal details
Name: (Last Name) : HOSSAIN (First Names) : MD ZAHID
Date/place of birth: 10 SEPT 1994, (CUMILLA) Nationality BANGLADESHI
:
Permanent address: PANIPARA, CHANDINA, CUMILLA

Email address: Zh01676009078.zh@gmail.com

Post code: 3510  No.: +880 1676-009078 (WA)
Mailing address: Same

Post code:  No.:

3 Education Background
School / College From To Highest Qualification Attained
CMC 2012 2014 PASSED (A+)

4 Identity documents
DOCUMENT COUNTRY NUMBER ISSUED PLACE EXPIRY
Passport: Bangladesh BE0754058 05 SEP 2019 DHAKA 04 SEP 2024
Seaman book: National C/O/8334 15 SEP 2019 CHITTAGONG 14 SEP 2029
Bahamian
Liberian
Panamanian
Other
Do you hold a US Visa ‘C1’?
Do you hold a US Visa ‘D’?
Have you been rejected for any visa applied for?
If YES, please state the country and reasons

5 Family details
NEXT OF KIN (relation) : MOTHER
Name: (Last Name) : AKTER (First Names) : JASMIN

Address: PANIPARA, CHANDINA, CUMILLA

Post code: 3510
Contact telephone numbers: 1st. 2nd.
Email Address:
Names of Children Sex Date of Birth

Page 1 of 4
6 CERTIFICATE OF COMPETENCY RANK: GRAD - 3
Issuing Country Certificate No. Date Issued Place Issued Valid Until
BANGLADESH 1.DC3.000121 10 MAY 2022 DOS 21 OCT 2027

7 Dangerous Cargo Endorsements- NATIONAL

Certificate No. Date Issued Place Issued Valid Until
Petroleum
Liquefied Gas
Liquid Chemicals
Other

8 Dangerous Cargo Endorsements (Issued by countries other than in Section 7)

Country/Type Certificate No. Date Issued Place Issued Valid Until

9 Courses attended and certificates obtained

Course Institution Place Date Certificate No. Valid Until
GENERAL/ MANDATORY
GMDSS UMA DHAKA 10-05-2022 GMDSS-1997/17 21-10-2027
PERSONAL SURVIVAL CMC DHAKA 17-09-2019 039.055195 08-11-2024
TECHNIQUES
PERSONAL SAFETY AND CMC DHAKA 17-09-2019 042.055196 08-11-2024
SOCIAL RESPONSIBILITY
FIRST AID* CMC DHAKA 17-09-2019 041.055197 08-11-2024
( ELEMENTARY)
PROFICIENCY IN SURVIVAL UMA DHAKA 30-05-2021 043.050253 19-05-2026
CRAFT AND FAST RESCUE
BOATS
ADVANCED FIRE FIGHTING UMA DHAKA 30-05-2021 045.050248 19-05-2026

SHIP SECURITY OFFICER UMA DHAKA 30-05-2021 048.050255 19-05-2026

MEDICAL FIRST AID UMA DHAKA 30-05-2021 046.050250 19-05-2026

NON-STCW ‘10
BRIDGE TEAM UMA DHAKA 30-05-2021 063.050249 19-05-2026
MANAGEMENT( DECK OFF)
EFFICIENT DECK HAND UMA DHAKA 30-05-2021 067.050261 19-05-2026

ECDIS( DECK OFF) UMA DHAKA 30-05-2021 059.050252 19-05-2026

RADAR NAVIGATION UMA DHAKA 30-05-2021 051.050254 19-05-2026

ENGINE SIMULATOR
TANKER SPECIFC
TANKER FAMILIARISATION CMC DHAKA 17-09-2019 030.055190 08-11-2024
COURSE
ROC ARPA UMA DHAKA 30-05-2021 052.050251 19-05-2026

SECURITY AWARNESS CMC DHAKA 17-09-2019 049.055192 08-11-2024

TRAINING
DESIGNATED SECURITY CMC DHAKA 17-09-2019 050.055193 08-11-2024
DUTIES

Page 2 of 4
10 Record of previous service

(Please give a full record starting with the last vessel on which you served)

VESSEL # TYPE OF YEAR FLAG GRT ## B.H.P. RANK SIGN SIGN DAYS
COMPANY TYPE OF ENGINES
VESSEL OF ON OFF ON
### BUILT
MAKE & TYPE ** DATE DATE BOARD

MV AMIS WISDOM BULK 2018 LIBERIA 31555 7730 2/O 27-07- 21-04- 8+
NATURE LINE 2021 2022
MT CHEM MARINE OIL & 1998 SINGAP 20055 7980 3/O 06-03- 08-12- 9+
TRUST CHEMICAL ORE
GUARD 2020 2020
MT MR STAR CHINA SUN OIL & 2000 PANAMA 27915 7980 3/O 10-11- 28-08- 9+
CHEMICAL
2018 2019
MV NIAMUL AK SHIP BULK BANGLA 20046 5446 D/C 30-06- 17-07- 1
MANAGEMEN DESH
MOWLA 2016 2016
MT PIONEER T
EASTERN OIL & KOREA 8446 5446 D/C 29-04- 19-04- 11+
TANKER CHEMICAL
SPIRIT 2015 2016

Please ensure that the full name and address of your immediate past employer is entered in section 14 Required for engineer applicants only Please enter details
In case of LPG- please specify if Pressurized or Refrigerated( or semi- if applicable)

Page 3 of 4
11 Medical history
Have you ever signed off a ship due to medical reasons? NO
Have you undergone any operation in the past? NO
Have you consulted a doctor during the last 12 months for an illness/accident? NO
Do you have any health or disability problems now? NO

(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)

12 General
Have you ever been the subject of a court of enquiry or involved in a maritime accident? NO
Have you ever had a professional license suspended or revoked? NO

(If YES, please give full details and attach a separate page if necessary)

13 Working Gear
Boiler Suit Size(9 S/M/L/XL/XXL) XXL
Safety Shoe size: 42

14 References (Please give the name and address of your current or immediate past employer)
Name of company
Name of person to contact
Address

 No.

15 References (Please list two contactable referees or past employers in addition to Section 14)
Name of company
Name of person to contact
Address

 No.

16 Automatic review
If immediate employment is not available do you wish to be considered for future vacancies? YES
If YES, please give any alternative contact details not shown in Section 2

17 Declaration
I hereby declare that the above particulars are true and authorise you to contact the referees listed above.

ZAHID HOSSAIN Date:

Signature

Page 4 of 4