DOLPHIN SHIIP MANAGEMENT & CONSULTANCY (P) Ltd
Seafarer Application Form 1
ISO 9001-2015 CERTIFLY SHIPPING COMPANY
ADDRESS REG .OFF .Chennai Affix latest
Indus campus Manali Saravana st, Photo
Kumananchavadi, Mangadu Chennai-600122, India,ContactNO:- +91 44 627
Email id:- info@dolphinshipmanagement.com/dsmchennai@gmail.com
website : www.dolphinshipmanagement.com
Position Applied For: Date Of Application:
Are you willing to accept a lower Rank? Date Of Availability:
INDOS NO: Crew IPN:
PERSONAL DETAILS
1. GENERAL (Last name) (First Name)
Name:
Date/ Place Of Birth: Nationality:
Parmanent Address:
Post Code (No.
E-mail Address: ÈNo.
Present Address:
(No.
Post Code ÈNo.
Civil Status: Single/ Married/ Separated/ Divorced/ Widowed.
Height: cm: Weight: Kg:
Boiler Suit Size: Shoe Size:
2. FAMILY DETAILS
Full Name Of Next Of Kin: Relationship
Address Of Next Of Kin:
Post Code:
Contact Telephone No. (No. ÈNo.
PPT.
Family Data Name D.O.B No. D.O.I P.O.I D.O.E ECNR
Wife
Child(M/F)
Child(M/F)
Child(M/F)
Child(M/F)
TRAVEL DOCUMENTS & VISA
Passport No. Date of Issue place of Issue Date of Expiry ECNR Blank Pages
U.S Visa MUI Membership No. D.O.E
Type:
Any Other Visa
Yellow Fever
ACADEMIC QUALIFICATIONS
School
College
Pre-Sea Training Institute
CERTIFICATIONS & COURSES
1. CDC DETAILS
Seaman's Book Number Date of Issue Date of Expiry Issuing Authority
Indian/ National
Liberian
Panamian
Marshall Islands
Bahamas
Cyprus
Other
2. LICENSES/ CERTIFICATE OF COMPENTANCY
License Grade Number Date Of Issue Date of Expir Issuing Authority
Indian/ National
UK
SINGAPORE
AUSTRALIA
NEW ZEALAND
PANAMA
Other
3. DETAILS OF COURSES & CERTIFICATES.
Course Type Number Date of Issue
Date of Expiry Issued By
Advanced/ Basic Fire Fighting/ FPFF
Proficiency in Survival Craft/ Rescue Boat/ PST
Elementary/ Medical First Aid/ Medicare
Personal Survival & Social Responsibility(PSSR)
Radar Observer/ ARPA
Radar Simulator (RANSCO)/ ENS
Ship Handling Simulator/ NARAS
LCHS
GMDSS
Specialised Petroleum Tanker Safety (STPOTO)
Specialised Chemical Tanker Safety (CHEMCO)
Specialised Gas Tanker Safety (GASCO)
Oil Tanker Familiarisation (OTFC)
Chemical Tanker Familiarisation (CTFC)
Gas Familiarisation (GTFC)
Ship Simulator/ Bridge Team Management
Engine Room Simulator
ECDIS
Bridge Team Management
Revalidation Course
ISM Code
ISPS/ Ship Security Officers Course/ CSO
Bridge/ Engine Room Resource Management
National Watch Keeping Certf. for AB/MTM/OILER
OTHERS
MISCELLANEOUS
4. OIL DCE
License Level Number Date of IssueDate of Expiry Place of Issue
Indian/ National
Liberian
Panamian
Marshall Islands
Bahamas
Cyprus
Others
Others
5. CHEMICAL DCE
License Level Number Date of IssueDate of Expiry Place of Issue
Indian/ National
Liberian
Panamian
Marshall Islands
Bahamas
Cyprus
Others
Others
REFERENCES
References Person Name of company (No. ÈNo.
DECLARATION
I hereby affirm that all this information provided by me in this application is true and correct to the best of
my knowledge and belief; further, that no certificate off competency or License issued to me has ever been
Revoked or Suspended. I also certify that my medical history contained above is true and any false
statement or undisclosed material information about past illness or injury will disqualify me from any
employment benefits and claims.
Date…………………………….. Rank…………………………….… Signature of Seaman………………………………
SPACE FOR OFFICIAL USE
Assessment: (1-5) Grade Application Status:Date:
Personality Forwarded To Dubai
Attitude Entered In Bass
Technical Knowledge Ex- Staff/ New
Overall Assessment
Others Specify
Rev. 00/2020
PREVIOUS SEA SERVICE
(Date Commencing From Last vessel)
Name of
SR. Owners/ Engine Total Reason
No. Manger Name of Vessel Type DWT GRT BHP Type Rank From To MM/DD for S/Off
10
11
12
13
14
15
16
17
18
19
20
