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FLEET PERSONNEL ADMINISTRATION

SEA STAFF APPLICATION FORM

PHOTO

APPLICATION FOR POSITION AS

3rd ENGINEER

OTHER POSITION (IF ANY)

1. PERSONAL DETAILS
TITLE MR/MRS/MISS

MR

SEX

MALE

FEMALE

SURNAME

NARE

FIRST NAME

GAURAV

OTHERS NAMES

DATE OF BIRTH

15 FEB 1985

PLACE OF BIRTH

MUMBAI

NATIONALITY

INDIAN

MARITAL STATUS

UNMARRIED

COLOUR OF EYES

BLACK

COLOUR OF HAIR

BLACK

MOTHERS NAME

VARSHA NARE

FATHERS NAME

VILAS NARE

173

WEIGHT (KG)

73

MOTHERS MAIDEN NAME

HEIGHT (CM)

NEAREST INTERNATIONAL AIRPORT:

2. ADDRESS

MUMBAI

ADDRESS (TEMP.) FROM/TO:

NO & STREET

18/803,SAFFRON,REGENCY
ESTATE,KALYAN SHIL ROAD

NO & STREET

CITY

DOMBIVLI EAST

CITY

POST CODE

421203

POST CODE

COUNTRY

INDIA

COUNTRY

TEL. NO.

TEL. NO.

MOBILE

7738821243/7506364819

MOBILE

E-MAIL

gvnare@gmail.com

E-MAIL

FAX

FAX

3. NEXT OF KIN
FULL NAME

VILAS GOVIND NARE

RELATIONSHIP

ADDRESS

18/803,SAFFRON,REGENCY ESTATE,KALYAN SHIL ROAD,THANE DIST DOMBIVLI EAST

Figure 03, Revision 001, Dated 01.05.09

1 of 6

FATHER

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FLEET PERSONNEL ADMINISTRATION

CITY

COUNTRY

DOMBIVLI

TEL. NO.

MOBILE

INDIA

FAX NO.

9967764819

4. CHILDREN
FULL NAME OF CHILD

DATE OF BIRTH

SEX
M

5. TRAVEL DOCUMENTS
TYPE

DOCUMENT NO.

ISS.DATE

EXP. DATE

ISS. BY (AUTHORITY)

PASSPORT

G 2091699

21/02/2007

20/02/2017

INDIA

THANE

PLACE OF ISSUE

SEAMAN BOOK

MUM 148259

13/02/2009

12/02/2019

INDIA

MUMBAI

OTHER SEAMAN BOOK

MH 368136

01/08/2014

21/07/2019

MARSHALL ISLAND

VIRGINIA,USA

US C1/D VISA

H8817629

26/12/2013

23 /12/2018

USA

MUMBAI

OTHER VISAS

6. BANK ACCOUNT INFORMATION

BANK NAME

AXIS BANK

BRANCH

DOMBIVLI EAST

CITY

DOMBIVLI

COUNTRY

INDIA

SORT CODE

UTB0000125

BANK ADDRESS
ACCOUNT NO

BANK SWIFT CODE

BANK TEL. NO

060010100388054
0251-2800671

ACCOUNT OWNERS NAME

GAURAV VILAS NARE

ACCOUNT OWNERS ADDRESS

18/803,SAFFRON,REGENCY ESTATE,KALYAN SHIL ROAD,DOMBIVLI EAST DIST.THANE

7. EDUCATION
SCHOOL NAME

FROM

1989

TO

2001

S.H.JONDHALE VIDYA MANDIR

SCHOOL NAME

FROM

TO

8. PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY

CERTIFICATE NAME

NUMBER

ISSUE DATE

EXPIRY
DATE

ISSUED BY
(AUTHORITY)

ISSUED AT

CL IV INDIA

95Z-12416

08/12/2010

06/02/2020

INDIA

MUMBAI

DANGEROUS CARGO ENDORSEMENT

NUMBER

ISSUE DATE

EXPIRY DATE

PETROLEUM

M/0/2/E/12/19856

29/08/2012

31/12/2016

CHEMICAL

M/C/1/E/13/23280

05/06/2013

31/12/2016

GAS

9. LANGUAGES

Figure 03, Revision 001, Dated 01.05.09

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FLEET PERSONNEL ADMINISTRATION

ENGLISH

FLUENT

GOOD

FAIR

POOR

GERMAN

FLUENT

GOOD

FAIR

POOR

FRANCH

FLUENT

GOOD

FAIR

POOR

SPANISH

FLUENT

GOOD

FAIR

POOR

ITALIAN

FLUENT

GOOD

FAIR

POOR

RUSSIAN

FLUENT

GOOD

FAIR

POOR

MARLINS TEST / LEVEL

ISSUED DATE

RESULT %

ISSUED BY (AUTHORITY)

ISSUED AT

10. HEALTH CERTIFICATES & VACCINATIONS

FLAGE STATE

ISSUE
DATE

NUMBER

EXPIRY
DATE

ISSUED BY
(AUTHORITY)

ISSUED AT

INTERNATIONAL
LIBERIAN
NORWEGIAN
PANAMANIAN
NAME
YELLOW FEVER

ISSUE DATE

EXPIRY DATE

ISSUED BY (AUTHORITY)

ISSUED AT

04/12/2018

INDIA

MUMBAI

5/12/2008

11. SAFETY CLOTHING

BOILERSUIT SIZE

BOOTS SIZE

XL

12. MARINE COURSESI

COURSE NAME
PERSONAL SURVIVAL
BASIC FIRE FIGHTING
ADV. FIRE FIGHTING
ELEMENTARY FIRST AID

NUMBER
SGA/PST/2007-802-10537

ISSUE
DATE

EXPIRY
DATE

ISSUED BY
(AUTHORITY)

ISSUED AT

22-12-2007

21-12-2012

SAGAR GYAN

MUMBAI

FPFF/8006/2008

12-01-2008

11-01-2013

OERC ACADEMY

MUMBAI

BPMA/AFF/RF/181/2015

27.01.2015

26.01.2020

BP MARINE

MUMBAI

27.12.2012

EFA/2825/2007

28.12.2007

OERC ACADEMY

MUMBAI

BPMA/ENGR-UP/28/2015

07.02.2015

BP MARINE

MUMBAI

PERS. SAFETY & SOC. RESP.

BPMA/ENGR-UP/28/2015

07.02.2015

BP MARINE

MUMBAI

PROF. IN SURVIVAL CRAFT &

RESCUE BOATS

RPSCRB C/B44/03

31.01.2015

HIMT

CHENNAI

OIL TANKER

BPMA/TFC/829/2008

14.11.2008

BP MARINE

MUMBAI

ADVANCE OIL TANKER

BPMA/ATOT/453/2011

15.10.2011

BP MARINE

MUMBAI

BPMA/CTFC/894/2008

21.11.2008

BP MARINE

MUMBAI

STC/02/13/032

29.03.2013

MEDICAL FIRST AID

MEDICAL CARE

FAST RESCUE CRAFT

G.M.D.S.S.
A.R.P.A. (Management level)
RADAR OBSERVATION
HAZMAT

CHEMICAL TANKER
ADVANCE CHEM ANKER
GAS TANKER
ADVANCE GAS TANFC/KER

Figure 03, Revision 001, Dated 01.05.09

3 of 6

MASSA

MUMBAI

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FLEET PERSONNEL ADMINISTRATION

CRUDE OIL WASHING

INERT GAS PLANT
ISM CODE
SHIP SECURITY OFFICER
BRIDGE TEAM MANAGEMENT
DP INDUCTION
DP SIMULATOR
BRIDGE / ENGIINE ROOM
RESOURCE MANAGEMENT.
SHIP HANDLING
INTERNAL AUDITORS COURSE
STSCSD

STS/55/13/1120

20.12.2013

MASSA

MUMBAI

12. MARINE COURSES (CONTD)

COURSE NAME

ISSUE
DATE

NUMBER

EXPIRY
DATE

ISSUED BY
(AUTHORITY)

13. SPECIALISED EXPERIENCE

TYPE

FROM

TO

COMMENTS

NEW BUILDING
SPECIALISED PROJECTS
SPECIAL TRADES
SHORE EXPERIENCE

Figure 03, Revision 001, Dated 01.05.09

4 of 6

ISSUED AT

COMPLETE SEA SERVICE DETAILS

( LAST VESSELS FIRST )
NAME:

GAURAV VILAS NARE

COMPANY NAME

RANK:

RANK

SIGNED

VESSEL NAME

ON

AVALIABILITY
DATE:07 JULY
2015
ONWARDS

3/E

SIGNED
OFF

PERIOD
IN
MONTHS

TYPE OF
VESSEL

(eg 4.2)
NAVIG8 SHIP MGMT
NAVIG8 SHIP MGMT
NAVIG8 SHIP MGMT
GENMARCO
SOVEREIGN SAFESHIP
FIVE STAR SHIPPING

3/E
3/E
4/E
4/E
4/E
5/E

M.T NAVIG8 FAITH

21.05.2014

23.11.2014

6.1

M.T.ZHONGJI NO.2

18.03.2014

05.05.2014

1.7

M.T.ZHONGJI NO.1

20.06.2013

05.12.2013

5.5

M.T. MORNING GLORY V

M.T.UNION PRIDE
M.T.MAHA GAYATRI

20.10.2011
28.01.2011
24.03.2009

01.04.2012
18.05.2011
09.11.2009

Product Tanker
Oil Chem Tanker
Oil Chem Tanker

5.5
3.7

Oil Tanker

7.6

Bulk carrier

Product Tanker

ENGINE TYPE
D.W.T.

( ENGINEERS
ONLY)

NAVIG8 SHP MGMT

ADDRESS

B-210,EVEREST GRANDE,ANDHERI EAST

PHONE NO.

022 6606 0000

FAX/E-MAIL

Fleet@nave.dig8shipmanagement.com

CONTACT PERSON

MR.AJIT KESARKODI

DATE

KW

MAN B&W

11610

8530

WARTSILLA

12730

9360

WARTSILLA

12730

9360

MAN B&W

13510

9930

HANSHIN

4500

3300

SULZER

11550

8490

REFERENCE CONTACT DETAILS

COMPANY NAME

BHP

SIGNATURE

Ref .No

Officer Application Form

(For Official Use)

Medical History
Have you ever signed off from a ship due to medical reasons?

(If yes give details)

*yes/no
Date of occurrence
(dd-mmm-yyyy)

Name of Vessel

Brief Description Of illness/Injury/Accident

Details
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)

*Yes/No
Details

Do you have any bodily defects or deficiencies?

(If Yes give details)

*Yes/No
Details

Are you currently suffering from any ailment or disease that is likely to render you unfit for
sea service or likely to endanger the healthy /well being of others onboard?
(If Yes give details)

*Yes/No
Details

Are you addicted to alcohol or drug of any kind?

(If Yes give details)

*Yes/No
Details

Are you suffering from an ailment that requires you to be on a long -term
treatment/medication?
(If Yes give details)

*Yes/No
Details

Have you ever deported or banned from entering any country?

(If Yes give details)

*Yes/No
Details

Have you ever been convicted of a criminal or drug offence or have any pending offences?
(If Yes give details)

*Yes/No
Details

Do you have any obligations towards your current/previous employers?

(If Yes give details)

*Yes/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.
..
dd-mmm-yyyy (Format)

..
Signature