Synergy Maritime Recruitment Services Pvt. Ltd.

APPLICATION FORM Chennai

Position Applied for : THIRD OFFICER Availability to join Date : 15-Oct-17

Surname: PRAKASH Name: SATYA

9693843924 / sugarspicesatya@gmail.com PHOTO
Telephone No. / Email:

Date Of Birth 20-Jan-92 Place Of Birth Mokama

Nationality : Indian Marital Status : Unmarried

, F203 , OMKAR BAMHA , ADAI , NEW PANVEL, MUMBAI , MAHARASHTRA
Address :

Documents Number Place of Issue Date of Issue Date of Ex

Passport J9760909 PATNA 11-Oct-11

National CDC MUM194948 MUMBAI 16-Nov-11

U.S. Visa C1/D 2014332021002 MUMBAI 1-Dec-14

Grade/
Documents Number Place of Issue Date of Issue Date of Ex
Level

National Certificate of 2MFG

Competency (COC) IF35088 MUMBAI 30-Aug-16
Oil Endorsement BASIC
DCE01MUM16001607 MUMBAI 16-Sep-16
Chemical Endorsement

Gas Endorsement

COC - National

Panama COE

Liberia COE

Others Flag endorse

CDC - National

Panama SUPPORT
1191707 MUMBAI 22-Dec-14
Liberia 1191707 22-Oct-14
PSSR BPMA/PSSR/1047/2014 MUMBAI 21-Apr-14
PSCRB/ PST 160047 MUMBAI 29-Jan-16
AFF/ FPFF BPMA/AFF/1315/2015 MUMBAI 25-Jul-16
SCM/ MFA/ EFA BPMA/MFA/551/2014 MUMBAI 17-Apr-14
SSO/STSDSD BPMA/SSO/370/2016 MUMBAI 6-Apr-16
Academic Background

Qualification Name of City + Country From To

Obtained Institution

10th Std (SSLC) /

Equivalent DAV PUBLIC SCHOOL BEGUSARAI , BIHAR INDIA

FORM : M 01 Page 1 Of 2 Rev -2

Date : 02 Jan 2017
 Synergy Maritime Recruitment Services Pvt. Ltd.
APPLICATION FORM Chennai

12th Std (Hr. Sec) /

Equivalent DAV PUBLIC SCHOOL BEGUSARAI , BIHAR INDIA

Graduate / (Other)

Presea Training T.S CHANAKYA MUMBAI

Mates / Masters

2E/ CE Exams

FORM : M 01 Page 2 Of 2 Rev -2

Date : 02 Jan 2017
 Synergy Maritime Recruitment Services Pvt. Ltd.
APPLICATION FORM Chennai

Family Details (if married Please include Wife & Children) :

Place of
No. Name Relation D.O.B Sex Passport No Date of Issue
Issue

1
2
3
Previous Sea Experience (List service for last five years OR last ten vessels. List recent vessel first)

Deck (Trade & DWT) Type of Period Dates

Vessel's Name Company's Name Rank
Engine (Type & BHP) Vessel/Flag
From To
VLCC /
MARSHALL
M.T.ASHNA 301428 ISLAND WALLEM SHIP MANAGEMENT T.N.O 3-Jun-13 23-Feb-14

VLCC /
MARSHALL
M.T ASHNA 301428 ISLAND WALLEM SHIP MANAGEMENT T.N.O 6-May-14 6-Nov-14

AFRAMAX
M.T. SIGMA TRIUMPH 67221 /LIBERIAN WALLEM SHIP MANAGEMENT T.N.O 17-Dec-14 13-Jun-15

VLCC /
M.T SMITI 281396 INDIAN ESSAR SHIPPING LIMITED 3RD OFF 9-Nov-16 3-Sep-17

Last Employer name, PIC & Contact:

Summary of Sea going Experience

For all Officers: Period served on (yy/mm)

Handymax Panamax Cape Cntr- Feeder Ctnr- +4000 P/ Tanker Aframax VLCC LPG/ LNG Chemical

For Engineer Officers only : Period served on (yy / mm)

Sulzer B&W MAN Pielstick UEC Doxford Steam UMS CPP Cranes

Nationality of crews sailed with : INDIAN, RUSSIAN , UKRANIAN , PHILIPINO , PAKISTANI , BA Declaration by the Applic
Are you familiar with computer based PMS ? Please I understand that a strict medical exa
YES , SHIPMASTER PMS SYSTEM
specify. including Drug and Alcohol test as p
Have you been on board vessels during: requirements is a a condition of m
and I express my willingness to be
Drydocking: Y/N
Y New Construction : Y/N Major Conversion:Y/N
I undertake to provide the compan
(in which rankCADET (in which rank) (in which rank) officer full details of my previous m
I agree that the decision of the co
Incidents of Grounding / Fire / Explosion / Collision / officer is final.
Abandon Ship / Rescue / NO
Major oil Pollution / Drug Smuggling / Towed or I declare that there are no crimina
Towing another vessel investigations in progress against

Were you ever involved in a court of Enquiry for a I confirm that all my travel docume
NO
Maritime accident ? and in order. I understand that if m
Documents become invalid or res
time during the course of my emp
FORM : M 01 Page 3 Of 2 cannot be revalidated by Rev
me-2unde
Date : 02 Jan 2017
process, the contract of employme
terminate and all costs of repatria
borne by me.
 I declare that there are no crimina
investigations
Synergy Maritime Recruitment in progress
Services against
Pvt. Ltd.
APPLICATION FORM Chennai
I confirm that all my travel docume
and in order. I understand that if m
Documents become invalid or res
Has your present or previous certificate ever been NO time during the course of my emp
suspended / revoked ?
cannot be revalidated by me unde
process, the contract of employme
Have you ever been left stranded at a port? NO
terminate and all costs of repatria
borne by me.
Have you ever been involved in a criminal case : If yes NO
on any of the above , give details: I am /am not presently employed

Medical History & If my application is successful, I w

Height(cms) 178 Weight(kgs) 90 Blood Group B +VE to report at your office on or aft
Declaration

Do you suffer or have suffered from : Diabetes / High

Blood Pressure / Hepatitis / Epilepay / Nervous NO
Disorders/ Disturbed Vision Or Hearing / Vertigo If
yes, give details :

Are you a habitual user of Drugs / Narcotics / NO

Excessive Alcohol :

Is your MUI/ NUSI membership valid for current year? NOT A MEMBER
If Yes, provide information

Name Of Applicant Rank

Date of Application Signature of the Applicant

FORM : M 01 Page 4 Of 2 Rev -2

Date : 02 Jan 2017
 Synergy Maritime Recruitment Services Pvt. Ltd.
APPLICATION FORM Chennai

PHOTO

Date of Expiry

10-Oct-21

15-Nov-21

27-Nov-19

Date of Expiry

3-Aug-21

15-Sep-21

29-Sep-16

22-Dec-19

UNLIMITED

UNLIMITED

UNLIMITED

UNLIMITED

UNLIMITED

Grade /
Percentage

71

FORM : M 01 Page 5 Of 2 Rev -2

Date : 02 Jan 2017
 Synergy Maritime Recruitment Services Pvt. Ltd.
APPLICATION FORM Chennai

68

70

FORM : M 01 Page 6 Of 2 Rev -2

Date : 02 Jan 2017
 Synergy Maritime Recruitment Services Pvt. Ltd.
APPLICATION FORM Chennai

Date of Expiry

List recent vessel first)

Months / Days
Reason for S/off

CONTRACT COMPLETION

CONTRACT COMPLETION

CONTRACT COMPLETION

CONTRACT COMPLETION

ry of Sea going Experience

Framo & COP Pumps

Experience

Framo & COP Pumps

Experience

Declaration by the Applicant

I understand that a strict medical examination
including Drug and Alcohol test as per company
requirements is a a condition of my employment
and I express my willingness to be examined.

I undertake to provide the companys medical

officer full details of my previous medical history.
I agree that the decision of the company medical
officer is final.

I declare that there are no criminal/ police

investigations in progress against me.

I confirm that all my travel documents are valid

and in order. I understand that if my travel
Documents become invalid or restricted at any
time during the course of my employment and
FORM : M 01 cannot be revalidated by me underPagenormal
7 Of 2 Rev -2
process, the contract of employment will Date : 02 Jan 2017
terminate and all costs of repatriation will be
borne by me.
 Synergy Maritime Recruitment Services Pvt. Ltd.
APPLICATION FORM Chennai

FORM : M 01 Page 8 Of 2 Rev -2

Date : 02 Jan 2017