OPS/101
Rev. No. 6.1
17 Jun 2019
Formerly Known as: Mitsui O.S.K. Lines Maritime (India) Pvt. Ltd. Page 1 of 4
REGISTERED OFFICE: UNIT NO. 52, 5TH FLOOR, KALPATARU SQUARE, KONDIVITA LANE, OFF. ANDHERI KURLA ROAD,
ANDHERI (EAST), MUMBAI 400 059 TEL.: (022) 6150 7000 FAX: (022) 6696 08 88 / 2825 4820
BRANCH OFFICE (Kolkata): BRANCH OFFICE (Chennai):
VASUNDHARA BLDG., SPACE NO. 8, 5TH FLOOR, NO. 202, 2ND FLOOR, CAPITAL TOWERS, 180
2/7, SARAT BOSE ROAD, KOLKATA 700 020 KODAMBAKKAM HIGH ROAD, NUNGAMBAKKAM, CHENNAI – 600034.
TEL: (033) 4003 3700/701/702/704 FAX: (033) 4003 3715 TEL.: (044) 4292 9300 Fax: (044) 4292 9301
BRANCH OFFICE (New Delhi): 1301 – 1303, 13TH FLOOR, DEVIKA TOWER, 6, NEHRU PLACE, NEW DELHI – 110 019.
Tel: 91-11- 41677766 / 4167 7788 / 011 2648 1127 Fax: 91-11- 4167 7799
Email: apply@molmi.com Website: http://molmi.info/
How did you come to know about MOL / MOLMI ?
INSERT PHOTO
APPLICATION FORM PHOTOGRAPH
REMOVE PHOTO
Dear Sirs, COPY PHOTO
I hereby apply for the post of and am ready to join from
I enclose herewith copies of all licenses, certificates and courses that I have completed.
Last name: First name: Other names:
Birth Date : Birth Place : Nationality:
Marital Status: Wedding Date:
Height: cm Weight : kg Collar: cm Chest: cm
Waist: cm Shoes: Eyes: Hair:
Colour Colour
Country Number Date Issued Valid till Place Issued
Passport
USA C1/D Visa
Seaman Book
Seaman Book
Have you ever been rejected for any visa applied for (YES/NO) :
Yellow Fever Vaccination (Date & Place) : (Lamination not accepted)
Permanent Address: Present Address:
Pin: Pin:
Tel/Mobile: Tel/Mobile:
E-Mail : Skype ID:
Next of Kin : (Please enter wife's name if married)
Name : Relationship:
Address :
Pin:
Tel/Mobile: E-Mail :
Family Details:
Name Birth Date Birth Place P.P. No. Date Issued Place Issued Expiry
Wife:
Children: Sex
1
2
3
RECRUITMENT & PLACEMENT SERVICE LICENCE NO.: RPSL-MUM-064 VALID UNTIL 18.12.2021
OPS/101
Rev. No. 6.1
17 Jun 2019
Academic / Marine / Engineering Qualification and School / College attended : Page 2 of 4
Name of School / College/ Date Attended Degree, Diploma
Percentage of
Pre-Sea Training Institute/ Address or Certificate
Marks Obtained
Engineering College Received
From To
Maritime Licences now Held:
Certificate of Competency Issuing Country Number Date passed Date issued Place Issued Valid Until
Master / Class I
Chief Mate / Class II
2nd Mate / Class IV
ETO / any other _______
List of STCW / Other Courses completed: INDoS No.:
Courses Certificate No. Date Issued Place Issued Expiry Date
PST (As per STCW 2010)
PSCRB (As per STCW 2010)
AFF / FPFF (As per STCW 2010)
MEDICARE / MFA / EFA (As per STCW 2010)
PSSR (As per STCW 2010)
SSO / STSDSD (As per STCW 2010)
REFRESH & UPDATING TRNG. (As per STCW 2010)
GMDSS - NATIONAL
ISSUED BY _________________ (COUNTRY)
GMDSS ENDORSEMENT (IF GMDSS IS INDIAN)
ECDIS GENERIC (Approved by National Administration)
ROC (As per STCW 95 / 2010)
ARPA (As per STCW 95 / 2010)
RANSCO / RADAR SIMULATOR
SHIP MANOEUVRING & BRIDGE TEAMWORK
HIGH VOLTAGE (Approved by National Administration)
HIGH VOLTAGE (LIMITATION DELETED)
SHIP HANDLING SIMULATOR
GAS TANKER FAM. / SAFETY (As per STCW 95 / 2010)
- DCE FOR GAS TANKER(As per STCW 95 / 2010)
WATCHKEEPING CERT. (DECK - II/4 / ENGINE - III/4)
COP - ABLE SEAFARER (DECK - II/5 / ENGINE - III/5)
COC AS COOK (MLC 2006)
SEAFARER PROFILE REGISTRATION
Previous company : Contact Person: Tel.No.:
Have you experienced any major damage/grounding/court case ? Yes / No If yes, give details :
Did you suffer any accident which rendered you partially disabled? Yes / No If yes, give details :
OPS/101
Rev. No. 6.1
Please start from last vessel first. 17 Jun 2019
Sea Service Record :
Please enter number of containers / cars loaded etc. in Vessel Particulars column Page 3 of 4
Vsl's Particulars S/On Date S/Off
GRT BHP No. of cars/cont/HL Date Remarks
Manning Owner Crew Tonnage, etc
Type of Year Type Period
Name of Vessel Flag Agent Operator Nation- Rank
Vessel Built Type of M/E Make, of A/E on board
Company Manager ality DD-MMM-YY (Pls Early S/off reason
DWT KW Model, Cyl, Bore Dia, UMS/ use "-" separator) etc.
non-UMS
Click to add Exp. Sheet Office to verify vessel's particulars with CDC and Website.
Date : Place : Signature :
OPS/101
Rev. No. 6.1
17 Jun 2019
FOR OFFICE USE ONLY : Page 4 of 4
GENERAL APPERANCE, PHYSICAL ATTRIBUTES, DRESS, SENSE,
MANNERS & ATTITUDE
EDUCATIONAL / PRE-SEA / NAUTICAL / MARINE ENGINEERING BACK
GROUND
PASSPORT ISSUANCE - PERSONAL IDENTITY VERIFICATION
COMUNICATION SKILLS ACCORDING TO POSITION (ENGLISH
KNOWLEDGE)
EMPLOYMENT RECORD,
REASON FOR LEAVING PREVIOUS EMPLOYER
SAFETY AWARENESS, KNOWLEDGE OF ISM CODE, MARPOL, SOLAS,
ENVIRONMENTAL PERCEPTION (ISO 14001-EMS, 50001-EnMS)
EXPERIENCE WITH OTHER NATIONALITIES CREW. CROSS CULTURE
KNOWLEDGE
EXPERIENCE WITH VARIOUS PORT STATE CONTROL, FLAG STATE
INSPECTION,RIGHTSHIP INSPECTION, VETTING INSPECTION.
KNOWLEDGE OF TRADE IN SPECIAL AREAS LIKE WEST AFRICA,
INSPECTION BY PORT AUTHORITY, QUARANTINE AUTHORITY ETC.
FULLY AUTOMATED ENGINE-ROOM EXPERIENCE WITHOUT ELECTRICAL
OFFICER'S SUPPORT
STEAM POWERED / OTHER SP. AUX. MACH. EXPERIENCE LIKE BOW
THRUSTER, SHAFT GENERATOR ETC.
DRY DOCK / NEW DELIVERY EXPERIENCE
TYPE OF PMS EXPERIENCE
HEALTH CONDITION CONFIRMATION
EXISTING ILLNESS, IF YES, MAINTAINANCE DRUGS
ALCOHOL/SMOKING/TOBACCO HABIT CONFIRMATION
Comments:
Date Name Signature MUM / KOL / CHN / DEL
