Section 16 Record of Sea Service (AIl Pe!_"ils be ep1|e req a!

__d q& ryf:

i ii ;.rE i,lr.l i r; ni'{!a,,r. irii ,'i,;,. .

VESS EiI",
l'! lr.,l rl.1",. tllii

COMpAN{ I 'Ilpe of,Vossel

,1'r,-r

D'W]' ," GRI.

1'.r. ,,:i 1

-[- iliNK-l- iGil; i,i

Sign olif
AnctrTyper of
operation ii'l casie
(please de{ete Lu reqd)
I I Dz\ r'E DAT[)
of []P ves:rels _L _ _ _l__ mgL/J]' drl_rl dd / ngm_,1.
(+r.)-,-**:iJ 49._q)_._ 41-ot-{ lslt- 9.s-Le:ul.?%
t{"!1fl.r i Cneer> i-e* {21_
olio;lneg
-it*.e--".
f44P,Pl, J-eg:.--- 2€-. _**{*w*.!_w! -!r\\LIr,{
[5l{[oi! _?:1 2 LUV :\C )auo ldl ru / 2or,
;f
t-,/
_hLt1y"iu _2-q -A!rw--.--
I

f,fud Wt,;Doiv[ 92ott a.a/"..o"313.

att5'
-31/:2"./a { uL / .2a\
QPILO&-?
-eIL,p*[u:=
r-*-t
_rl!ad ri"
Fiiit9ft-, )en
-Hlefr
ct 1,'8
__-"T*r_
hp_ z+/ o,t,
6F"'toi
-3i,5D--, of / ozld
_..3"is?" :L?---._"-. !!-1 "csl:w!
OS/ o zi iy1 o; I z,a,
Bl-rgu.-: . *:!!3"_ ?U
Ef:lv/\u-Lb 24ov _-LQ ( tZ_ot \f,los/7.'li
-2-a--- ,tt -u_8
lotl?-tt T;i x'l-.:at
CAPI"VI 3tit 6angb
-i;D;,, J-p____-_
ii
,h
r 2,* 64 u --
-?t*o* w :WiW!I- o f { 01/,\ri
n--
i,oYft tla,trA t2 2tllot'' LV _1 .!_\\" lilrz *U-tW"Jt
Ju,pylr luaoa tr> z t\t49, 70 3 iL.l!*l-?'j.
-.-?$*lbziz

\,VPII] - M()l 23'd I]E,B 20 I5 Rev'06

Section 11 Medical Histo

otf a ship due medical reason ?

Have medical ooerations in
Ha.re yorr cor*",tted a doctor during the past 12 months for an illqqlq/49!rd9"t
Do u have health or disabiliry problem now ??
Tf ^--^---^--.^ ,-f ol-,-',o i c \'-FC f'lr+n -1- ^ ^+
li i .l +rill iU u^-^ tii uuu t L lJ a LJ uivu Ye f.:i1her details belorl, or o$ a

XOfg : Alt our clients have STRICT Alcohol and I)rug Policy, Which
means ZERO TOLEREI{CE for alcohol and dru
General

@olvedinamaritimeaccident,iegrounding,fire,E,.xplosion,
Coiiision, etc
ffibiect of a court of enquiry or involv"d in a maritime accided
Han e \rOU efref had a ional licence suspended or revoked
Have ever been convicted of any criminal ott'ence'l
Have ever beea dismissed
lf ,,* tt*rtrcf *bo-;-tG[pte*"?=tfO*tuit= t o**cr-.*ieparate sireet of

Section 13 Rel'erences Last Two Recent Em la ers

FT'^ A RI N
Ltagvv I Lv
Name Person to be contacted Bernard Caetano
nu a t nte rn atio na L* 1 000 ! G ra nj a d os C ava le i ro-s--L$-?-qaq,'-BJl!-ig4!j

com

BIBBY INTERNATIONAL
Name Person to be contacted

Santosh.m ndia.com
Section 14 An other information, you wish to add in

ion 15 laration BE SIGNED BY ALL .LqE&,Ig

- I\{UST you
@culars are true and to conact the referees listed above
I aurtrorize
And r.*nfirm that Atl nry e*rtifieafe.s I L.ic*nees ere Aslthentrc l SEASERVICE RECGRD is ACCURATE / And I
conlirm acceotins Comranies DRUG & ALCOHOL

Pa 4af7

WPIF-M/Oi 23'd FEB 2015 Rev - 06

 Sectiron OFFSHORE I}.IDUSTRY COURSES
rr^--^
rtclr!c ^I' r-^..-...,
r-!l L(,Llr:q
/ l.-,.: i {l^^r..
r- tiil,lL4ttr .TDDDlr\lIAI(l
Place Iccr:e Dqte Cert Nc I E

BOSIET
I

()hrsHoRh Mr,DlcArs I

| I

i t UK. NORWAY oTNETHERLAND ) I

Initiai Standby vessei crervs training ( 1TSO )

l-a I uai!.,^-rori
I !!Liili.ii-ii ^,.-^;,i* r lrrr,iupLlr/

Advanced Medical Aider ( AMA )

IFI TS-trrrolich TFQT hit r:: i /rlu, n', ie lts. crsltest centre si:arcltisearch resirlts.asp:l

i pt-vtS maintenance syst*un - Conlirm that you rre Familiar with its use { Ys:S / NO )

DEEP WATER ANCHOR HANDLING E)(PERIENCE ENTER DEPTHIN METERS I ???????

DP L{aintenance Courses
I\Dt Ll..l-.^-....,...
u /-....
LUul -.'--
StJ
^rtdiualtlatlll
HIGHVOLTAGE COURSE

Dlmamic Positioning lnduction Course

Dynamic Positioning Simulator Course
D.vnamic Positioning Operators
CERTIFICATE
Dynamic Positioning Log book Details

Section
ron 10 ours oone ith varlous Lrr sYsrem
don vylrn
SYSTEM DETAILS Approx Hours as SDPO / Approx Days Approx Hours as DPO / Approx Days
in case of Senior ETO i Senior Enginecr in casc of Junior ETO i.Iunior Enginecr

APPR.OXIMATE Total DP Hours in Various Operations

SAT DIVI},IG 700 r-AEII tr I AVT\Trl
AIR DTVING 700 SLTRVEY
ROV 3it0u PIPE LAYING
WELL STIMLTLATION / INTERVENTION / 2016 DRILL SHIP / SEMI SUB 3400
ACTIVATION
ann Ncll
r.'' v i ro
AI{TS 7
"+uo
FPSO SHUTTLE TANKER
CONSTRUCTION ROCK DI]MPING / MATTRESSING
COzuNG TRENCHiNG
HEAVY LIFT ACCOMMODATION / GANGWAY

WPIF - M/01 23'd FEB 2015 Rev - 06

SeCtiOn 6 STCWgs Hishest Certilicate of Competency / Licence HeId ( also list Flag State Endorsements)

Class / Issaing Country Certific*eNo. Dule Issaed Expiry Dernils of Limitolions

GradrJCaoacitv

a.Tr - ttt l4t4sT4-ltr0dtt, gP"9#e.€s{( 1,0 /tt {zou

mlfuPs64eF,r r'm-rn 3AVAvtA 6ffi258{laco 15 I ost
"ott
ALSO ENTER ABOYE DETAILS OF AI{Y OTIIER FLAG STATE CER NFICATES IIELD
Section 7 STCWgs Dangerous Cargo Endorsements
Certificate No. Date Issued Expires Details of Limitations/ Grade
Petroleum
f.furuofrpd Ca.t

Section 8 STCWgs related Courses Affendr d and Certi ficates Obtained

Name of Course / Certificate STCWCode Place Issue Date CertNo ExpirvDate
Basic Safety Training A-vi/1 xauA$,rA L6 loLtua Ltcoz*4("t,to A 25/x/xr
Basic Sea Survival I Personal Survival A- Vv1-l
Techniques
Fire Prevention& Fire Fighting A-YAL2
ElementaryFirst Aid A-]rI/1-3
Personal Safet-v & Social Respoasibility A-r\/14
Proficiency in Survivai Craft & Rescue A-Yl/ 2-1 5,2ooo2TQlf,
Boats latae;ta zElotltoU baot14 zs /ot/zatq
Proficiency in RESCLIE CRAFTS
Froficieacy in FAST RESCUE BOATS A-VA 2
Advanced Fire Fighting A.YY 3 loEepra zsloglTok yf(tr16' zr[alan
Medical & First Aid A-VA 4- f6Laeta csto6{zalq vgl*,94 w/oefp-ts
Medical Care A4114-2
( Shio Captaias Medical Course )
Radar & ARPA Simulator Trg- A-W t-2
Manasement level
Electronic cha* Display and A-fiI1
Lrforrration System course {ECDIS)
Gh4DSS + EI{DORSEMENT A.I1/I2
SAFETY OFFICERS COURSE (SO)
Ship Securify Officers Course (SSO) A-Yt/ 5 u'1, 62-00029vl
Issued under STCW95 )*vaq^a lorl on 6z4o?t{ tqf*lun
Proficiency in Security Arrareness A-Yy6 tl39tkatl
$Yavra ub4loou ?t fclttt lLtc s€/ottleotg
Proficiency in Desipated Security A-\,7
Duties
Medical Certificate / HEALTH Ltr ra
lYLU
Certificate Comnliant
DruE and Alcohol test certificate
YELLOW FEVER it{0crPesta 01 I q (aDV 900-sb#l oT{ltl2ot+,
Bridge TeamManagement A-fi/z
Bridge Resources Management B-Vmlz
ISMCode A.1441(18)
Engine Room Resources Management A-[yl, A-fiyz, 6Looo2lyz1. o5/o(,[?.oty.
( Ooerational Level / Manaeement level ) A-rIv3A-Vrrv2 fAk48A-4 sbl os I ut< Lz?o}t<
HELM A.IY2,
fleadershiu and manasement skills ) A-fiv2
TANKER.S FAMILT ARTSATION A-V/1
Advanced Tanker Operations (Chem.) A-Vtl-Z
Advanced Tanker Operations (Oil) A.V/1
Advanced Tanker Operations (LPG) A-V/1
REFRESI{ER & UPDATING IlTI &TIA2

wprF_M/ol ,?rd FFrl ?Ol {

 RYAN GROUP
RYAI{ OFFSHORE LTD / RYAI{ SHIP MA}JAGEMEI\T LTD
POSTAL ADDRESS:-RY.{NSHIP P O Box - 1282 - SUNDERLAND
Ta,3{E anrl '*IEAR SR5 9}1}i lj{llEl}&lregm
Tel: +44 191 54 888 59 Fax: +44 191 54 88 425
Email : o-ffiec@r-yan-ship rqanagpmgnt lg.qk
Web Site: \Yw'w'.n-aR-shirrma .uk

Apptication Forrra Deek & Engineering 0fficers

Section I Position
1 Position
Lowest Position A ?/Nn E/*{
fi $- t e o i AY{, il {, bil i; iU t !1lt!! d:te and ddirrrnlr-1'y,r

Personal Details

Firsl Name i Given Name MasP4L

Date & Pluce of Birth Dut. - o'4-' o'7 ; rgTgFiiie: 10
/ lYD O lV 6-.gz,a
1,
PermanentAddress ASE b xRU Ak /) LLl t+ tbLZ o t<€ c B
U sut- sFL //vn o />/L:stA
Present Address

i fP[ imf*rmation SiEE_iy;Jiojs_S_IZJ .99jig44WJU--i Xt=

B lood Grouo Information
Present Contuct Number
5 zt9 L\zz
SKYPE ADDRESS
Email Address cthwr,.te Q, 5''r^atv .Gu
Nu rtl pqisfo
Section 3 Passport and VISA details
Irt'lq3ttag I ,
Date Issued L4 Attu 2 ot{ | usA wsA
Place Issued TANluilg 0GtoE USA Visa - Type ClID
Passoort Number A, BDQYJig USA WSA Expires
Passoort -Exuires Lv KfA A-o1,3 Other Country Visa
Secondcry passport or Dual nationalitlt l'isa Exoin

Section 4 1ni-tigt t as required ) Seaman book / Discharge book / Seaman Record Book / CDC
I*"ins Cr"ntrv & Pt{r* Tffioo14'l Dnteltrued lll ltt lLotx
Exnin, Date {if anv} tl I tL lzol6
Number c) B I

Section 5 N ext offKi

l(.-ln - this is important information we require- llon't) ignore lt
Full Name / Relationshio 14Ag',[rNr MAURU O 6UA
An,* denendenfi,/ Children {incl use }

/ -t -1,_ -- -
/lilure3i3i ?AsrG bAsU -lbt0o_*!gqqLhqre___ ko. gtJ 0 _tuurtl-lU:er
Contact Nambers +6r Bt 31r 515
Ilage 3 *f T

WPIF _M/01 23'd FEB 2015 Rev - 06

 ADDITIONAL INFORMATION SHEET
VESSEL TYPE YOU ARE II{TERESTED IN (please list in order of priori
1

2.

4.
5.
MAXIMUM ACCEPTABLE CONTRACT PERIOD (Please indicate below

Please Quote -Consolidated MINIMUM MONTHLY SALARY ( no leave pay ) payable for
time onboard only or Working DAY RATE EXPECTATION ( no leave pay)
lease quote below in US$ -nreferred or Euro or GBFf,

Lan n / Written / Understood (1-ooor S-Fluent

ENGLISH

IIR{JG 8L ALCAfiOL POUCY

Ai.i- (iur Ciienis hsve very strict N{} DR{/{; arzd A!.Ci}Hi}!. P{}i.lt:'{, W'hieh is required to he
complied with at all times, whiclt t*eafts *"')ZBRA TOLERENCE on ALCOHOL & DRUG"""
{'---''- L :}-" "'-.-' *"-T
tuur uuuy fftuyt l\l-t hfiye any ALCOHOL or I}RLG sabstarccesfram the iiine yau boardyaurfiight
or commence your travel to join vessel, and Must remain so Until you have completedfull contract
and returnetl ia your home Airport / Tatpii
If during the said period you are found under the influence of DRUG or ALCOHOL then ALL
EXPENCES incurredwhichwill include all your travel and recruiting costs, And your relief's
Travel and recruiting casts, And Any other costs v:hatsoever incurred due to your NON-
COMPLANCEwiII be deductedfromyour salary, Whichttill include but not limited to "damoge to
vessel her equipxzents and machi.nerie,s, ioss af chcrter, and any ather costs Directly or indirect$;
c onne ct e d w ith y our NON-C O MP LANC E

FOLLOWIIG DOCUMENTS COPIES MUST BE SENT TO US- send to us In senarate Ernail

All Certificates / Courses Listed in this form * Licence or Certificate of competency, Any tanker
endorsements, GMDSS showing expiry date in case of Deck Officers, Medical Fitness / Examination
Certificate, Passport Main page, Seaman book or Discharge book Main pages, In case of DPO - DPO Cert,
DP LOG Pa
FOLLOWING ADDITIONAL DOCUMENTS will ALSO BE REOUIRED - Send to us in separate email
All short courses ceftificates ( STCW95 ), SSO ceftificate, Last 3-5 years ships entries in Discharge book or
Seaman book, Certificate of Equivelant Competency from other flag states
PAGE 7 of 7

w?rF - M/01 23'd FEB 20l5 Rev - 06