Mideast: 025 FLEET PERSONNEL ADMINISTRATION

MIDEAST SHIP MANAGEMENT LTD SEA STAFF APPLICATION FORM

PHOTO

APPLICATION FOR POSITION AS

3E

OTHER POSITION (IF ANY)

1. PERSONAL DETAILS
TITLE MR/MRS/MISS SURNAME FIRST NAME DATE OF BIRTH NATIONALITY COLOUR OF EYES MOTHERS NAME MOTHERS MAIDEN NAME HEIGHT (CM)
168 NEW DELHI MR. ANAAM SHAAZ 24/08/1982 Indian Black Habiba Khatun

SEX OTHERS NAMES PLACE OF BIRTH MARITAL STATUS COLOUR OF HAIR FATHERS NAME WEIGHT (KG)

MALE

Howrah Married Black Abdus Sattar 77

NEAREST INTERNATIONAL AIRPORT:

2. ADDRESS
NO & STREET CITY POST CODE COUNTRY TEL. NO. MOBILE E-MAIL FAX
B 1317 Gaur Global Village Crossing Republic, NH 24 Ghaziabad 201009 India 9313349388 9873011720 shaazanaam@gmail.com

ADDRESS (TEMP.) FROM/TO:

NO & STREET CITY POST CODE COUNTRY TEL. NO. MOBILE E-MAIL FAX
Anindita Neogy 250/1 Chiranjiv Vihar Ghaziabad Ghaziabad 01204116056

3. NEXT OF KIN
FULL NAME ADDRESS CITY TEL. NO. RELATIONSHIP COUNTRY MOBILE
9811440420 wife India

FAX NO. DATE OF BIRTH M M M M SEX F F F F

4. CHILDREN
FULL NAME OF CHILD

Figure 03, Revision 001, Dated 01.05.09 1 of 8

Mideast: 025 FLEET PERSONNEL ADMINISTRATION

5. TRAVEL DOCUMENTS
TYPE PASSPORT SEAMAN BOOK OTHER SEAMAN BOOK US C1/D VISA OTHER VISAS
C6633972 21/12/2010 19/12/2015 NEW DELHI

DOCUMENT NO.
F0136206 CL76302

ISS.DATE
28/12/2004 19/10/2005

EXP. DATE
27/12/2014 18/10/2015

ISS. BY (AUTHORITY)
INDIA MMD

PLACE OF ISSUE
KOLKATA KOLKATA

6. BANK ACCOUNT INFORMATION

BANK NAME BANK ADDRESS CITY SORT CODE BANK SWIFT CODE ACCOUNT OWNERS NAME ACCOUNT OWNERS ADDRESS ACCOUNT NO BANK TEL. NO COUNTRY BRANCH

7. EDUCATION
SCHOOL NAME
St Thomas Church school

FROM FROM

1987

TO TO

2000

SCHOOL NAME

8. PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY

CERTIFICATE NAME MEO class 4 NUMBER
95Z-9016

ISSUE DATE
06/07/2008

EXPIRY DATE
17/3/2013

ISSUED BY (AUTHORITY)
MMD

ISSUED AT
KOLKATA

DANGEROUS CARGO ENDORSEMENT PETROLEUM CHEMICAL GAS

NUMBER D/O/1/E/10/5011 D/C/1/E/09/3535

ISSUE DATE 25/11/2010 08/06/2009

EXPIRY DATE 02/10/2014 07/06/2014

9. LANGUAGES ENGLISH GERMAN FRANCH SPANISH ITALIAN RUSSIAN

MARLINS TEST / LEVEL
FLUENT FLUENT FLUENT FLUENT FLUENT FLUENT GOOD GOOD GOOD GOOD GOOD GOOD FAIR FAIR FAIR FAIR FAIR FAIR POOR POOR POOR POOR POOR POOR

ISSUED DATE

RESULT %

ISSUED BY (AUTHORITY)

ISSUED AT

Figure 03, Revision 001, Dated 01.05.09 2 of 8

Mideast: 025 FLEET PERSONNEL ADMINISTRATION

10. HEALTH CERTIFICATES & VACCINATIONS

FLAGE STATE INTERNATIONAL LIBERIAN NORWEGIAN PANAMANIAN NAME YELLOW FEVER ISSUE DATE
29/08/2005

NUMBER

ISSUE DATE

EXPIRY DATE

ISSUED BY (AUTHORITY)

ISSUED AT

EXPIRY DATE
29/08/2015

ISSUED BY (AUTHORITY)
MMD KOLKATA

ISSUED AT

11. SAFETY CLOTHING

BOILERSUIT SIZE
M

BOOTS SIZE ISSUE DATE EXPIRY DATE

12. MARINE COURSES

COURSE NAME
PERSONAL SURVIVAL BASIC FIRE FIGHTING ADV. FIRE FIGHTING ELEMENTARY FIRST AID MEDICAL FIRST AID MEDICAL CARE PERS. SAFETY & SOC. RESP. PROF. IN SURVIVAL CRAFT & RESCUE BOATS FAST RESCUE CRAFT G.M.D.S.S. A.R.P.A. (Management level) RADAR OBSERVATION HAZMAT OIL TANKER ADVANCE OIL TANKER CHEMICAL TANKER ADVANCE OIL TANKER GAS TANKER ADVANCE GAS TANKER CRUDE OIL WASHING INERT GAS PLANT ISM CODE SHIP SECURITY OFFICER BRIDGE TEAM MANAGEMENT DP INDUCTION DP SIMULATOR

NUMBER

ISSUED BY (AUTHORITY)

ISSUED AT

03029 MFA0020701725 PSSR010505444 03240

12/01/2007 27/01/2007 04/05/2005 19/01/2007

IIPM MMA KOLKATA MMA KOLKATA IIPM

KOLKATA KOLKATA KOLKATA KOLKATA

OTF/018/05 CTF/F-4973/2009

22/10/2005 06/06/2009

MMA KOLKATA MTA

KOLKATA MUMBAI

Figure 03, Revision 001, Dated 01.05.09 3 of 8

Mideast: 025 FLEET PERSONNEL ADMINISTRATION

BRIDGE / ENGIINE ROOM RESOURCE MANAGEMENT. SHIP HANDLING INTERNAL AUDITORS COURSE

12. MARINE COURSES (CONTD)

COURSE NAME NUMBER ISSUE DATE EXPIRY DATE ISSUED BY (AUTHORITY) ISSUED AT

13. SPECIALISED EXPERIENCE

TYPE NEW BUILDING SPECIALISED PROJECTS SPECIAL TRADES SHORE EXPERIENCE FROM TO COMMENTS

Figure 03, Revision 001, Dated 01.05.09 4 of 8

COMPLETE SEA SERVICE DETAILS

( LAST VESSELS FIRST ) NAME: RANK: SIGNED ON 17/01/2006 13/03/2006 01/09/2008 16/06/2009 18/02/2010 06/01/2011 SIGNED OFF 02/03/2006 31/12/2006 30/12/2008 03/10/2009 13/08/2010 21/04/2011 PERIOD IN MONTHS (eg 4.2)
MOL MOL MOL THOME SHIP MANAGEMENT GREAT EASTERN EXECUTIVE SHIP MANAGEMENT

AVALIABILITY DATE: TYPE OF VESSEL

VLCC CONT CONT OIL/CHEM OIL OIL/CHEM

ENGINE TYPE GT ( ENGINEERS ONLY)

MAN B&W SULZER MAN B&W MAN B&W MAN B&W MAN B&W

COMPANY NAME

RANK 5E 5E 4E 4E 3E
3E

VESSEL NAME

BHP

KW

MT OTOWASAN
MV MOL ENDURANCE MV MOL THAMES MT SITEAM ADVENTURER MT JAG LATA MT ALPINE MIA

1/17
9/20 4 3/18 5/24 3/17

160292

27160 50049 37180 8200 11473 9610

53096 50628 26751 57508 29266

REFERENCE CONTACT DETAILS

COMPANY NAME ADDRESS PHONE NO. FAX/E-MAIL CONTACT PERSON I declare that the information I have given is, to the best of my knowledge, true and complete. I also declare that the documents submitted are genuine, given and sign by persons whose names appear on them.

17/11/2011
DATE

SHAAZ ANAAM
SIGNATURE

Officer Application Form

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

Ref .No (For Official Use)

(If yes give details) Name of Vessel Date of occurrence (dd-mmm-yyyy)

*yes/no

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) Do you have any bodily defects or deficiencies?

*Yes/No Details

(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) Are you addicted to alcohol or drug of any kind? *Yes/No Details

(If Yes give details) Are you suffering from an ailment that requires you to be on a long -term treatment/medication? (If Yes give details) Have you ever deported or banned from entering any country?

*Yes/No Details

*Yes/No Details

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

*Yes/No Details

(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