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Click here or scroll down to respond to this candidate APPLICATION FOR POSITION AS: THIRD OFFICER/JUNIOR OFFICER TDPO
Surname: AMBROSE First Name: Candidate's Name
Nationality: INDIAN Date of Birth: Street Address -11- Age: 26 Place of Birth: CHENNAI
Street Address YEARS
OTHER PERSONAL DETAILS
HEIGHT: Street Address cm WEIGHT: 83 kg COLOUR OF EYES: BLACK
COLOUR OF HAIR: BLACK DISTINGUISHING MARKS: A MOLE ON RIGHT UPPER LIP
Passport
Number Place of Issue Date of Issue Date of Expiry Issuing Authority Blank Pages
Passport Office
J8084012 CHENNAI 26/08/2011 25/08/2021 21
CHENNAI
Seamans Book(CDC)
Number Place of Date of Issue Issuing Date of Remark
Issue Authority Expiry
DG
MUM 203123 MUMBAI 02/07/2012 SHIPPING 01/07/2022
MUMBAI
Certificate of Competency(COC)
Number Place of Date of Issue Issuing Date of Remark
Issue Authority Expiry
* Indicate either yes or no
GMDSSCHN16 CHENNAI 14/10/2016 MMD 13/10/2021
001433 CHENNAI
IF35676 MUMBAI 23/11/2016 DG 06/11/2021
Medical Fitness Certificate
Date of Issue Date of Expiry
Yellow Fever Vaccination
Date of Issue Date of Expiry
24-09-2012 23-09-2022
Full address: NO: 3/1 DR.RADHAKRISHNAN STREET, VIVEKANANDA NAGAR, KODUNGAIYUR, CHENNAI
Postal Code: 600118
Country: INDIA
E-mail id: EMAIL AVAILABLE
Home telephone no: - PHONE NUMBER AVAILABLE
Contact/Mobile phone: PHONE NUMBER AVAILABLE,PHONE NUMBER AVAILABLE
Domestic Airport: CHENNAI International Airport: CHENNAI
Marital Status: SINGLE
Full Name of Next of Kin: PETER ANTONY Relationship: BROTHER
Address of Next of Kin: NO: 3/1 DR.RADHAKRISHNAN STREET, VIVEKANANDA NAGAR,
KODUNGAIYUR, CHENNAI
Dependents (if married)
Name Date of Birth Age Gender Relationship
* Indicate either yes or no
Details of other marine courses / STCW short course certificate
Type of Marine Course Place of Issue Number Date of Issue Date of Expiry
DIPLOMA IN NAUTICAL
SIMS/LNV/D13/2
SCIENCE-PRE SEA LONAVALA 31/07/2012
012/47
DECK COURSE
GMDSS CHENNAI GOC-C-5129 27/02/2014 26/02/2024
Basic Fire Fighting CHENNAI FPFF/8280/2012 02/09/2012
Radar Course CHENNAI ROS C/B02/01 26/12/2015
ARPA CHENNAI ARPA C/B02/10 01/01/2016
Proficiency in Survival
CHENNAI PSCRB/B531/01 15/01/2016
Craft & Rescue Boat
PSSR CHENNAI PSSR/B1441/12 23/01/2016
SIMS/LNV/ECDI
ECDIS LONAVALA 30/01/2016
S/02/2016/16
SSO CHENNAI SSO/BPHONE NUMBER AVAILABLE016
SIMS/LNV/EFA/0
EFA LONAVALA 10/01/2012
02/2012/029
SIMS/LNV/PST/0
PST LONAVALA 17/01/2012
4/2012/69
AFF CHENNAI AFF/BPHONE NUMBER AVAILABLE016
RMFA/B142/REO
MFA CHENNAI 04/02/2016
/B207/13
SIMS/LNV/OTFC
OTFC LONAVALA 18/08/2012
/X/2012/16
SIMS/LNV/CTFC/
CTFC LONAVALA 11/08/2012
IX/2012/16
PMA/GTFC/08/4
GTFC PONDICHERRY 25/11/2016
7/2016
PMA/STPGTO/0
GASCO PONDICHERRY 09/12/2016
2/24/2016
OFFSHORE COURSE CERTIFICATES
BOSIET MUMBAI 24/01/2015 23/01/2019
RIGGING AND MSTS ASIA -
5685524 11/02/2015 10/02/2018
SLINGING MALAYSIA
BASIC HYDROGEN BSTS- BSTS/HSE-
12/02/2015 11/02/2017
SULPHIDE TRAINING MALAYSIA 01/00849/15
* Indicate either yes or no
Employment History (Starting with Latest Sea Service)
TYPE OF VESSEL
Total Type of Deck: NAME/Type / GRT Reason for
From To Rank Company
MM/DD voyage Engine: Type / BHP / Main leaving
Engine
M.T. ALQADISIA / OIL EXECUTIVE SHIP Contract
14.03.13 27.12.13 09/15 FG D/C
TANKER/ 9343352 MANAGEMENT finished
M.T.PACIFIC POPPY / EXECUTIVE SHIP Contract
22.06.14 24.10.14 04/03 FG D/C
OIL TANKER/ 9514171 MANAGEMENT finished
M.V. EXECUTIVE EXECUTIVE
18/02/20 03/08/20 Contract
VALOUR / MPSV DP-II /
05/14 FG D/C OFFSHORE PVT
15 15 finished
9615626 LTD
Medical History
No
Have you ever signed off from a ship due to Medical reasons?
(If Yes give details)
Name of Vessel Date of Occurrence
Brief Description of Illness / Injury / Accident
No
Have you ever suffered from any ailment or disease in the past that is likely to render you
unfit for sea service or likely to endanger the health/well being of others onboard?
(If Yes give details)
No
Do you have any bodily defects or deficiencies?
(If Yes give details)
No
Are you currently suffering from any ailment or disease that is likely to render you unfit
for sea service or likely to endanger the health/well being of others onboard?
(If Yes give details)
No
Are you addicted to alcohol or drug of any kind
No
Are you suffering from an ailment that requires you to be on a long-term
treatment/medication?
(If Yes give details)
No
Have you ever been deported or banned from entering any country?
(If Yes give details)
No
Have you ever been convicted of a criminal or drug offence?
(If Yes give details)
* Indicate either yes or no
I hereby affirm that all the information provided by me in this application is true and correct to the best of
my knowledge and belief; further, that no Certificate of 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; Candidate's Name
NOTE:
* Indicate either yes or no
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