Chennai:

2nd Floor Sai Building, Old 62/1 New 79/1, Lloyds Road, Royapettah, Chennai 600014
Tel: +91 44 4684999 Fax: +91 44 28475288 crewing@nautilusshipping.com
RPSL NUMBER:RPSL/CHN/012 VALID UNTIL 16.12.2018

Application Form
App No:

Rank Applied For : 2nd Officer Availability Date :

Nearest Airport New Delhi
First Name Rohan Middle Name Last Name
Date of Birth : 1/3/1987 Place of Birth /State: Agra/Uttar Pradesh Nationality :
Present Rank 2nd Officer Vessel (Present): OSV Vessel (Preferred)
Marital Status Single Zone North Experience

Permanent Address : 130/A Nehru Nagar Present Address : Dwarka Sector - 9 Pocket 2 DDA FLAT

City Agra State Uttar Pradesh City New Delhi

Pincode 282002 Pincode

Phone : 9319206422 Phone : 9
Mobile: 8130463356 Mobile : 8
Email : rohanpaliwal@live.com Email: rohanpaliwal@Live.com
skype id

Date of
Documents Grade Number Place of Issue
Issue
Certificate of Competency SECOND MAIF 39017 5/9/2018 Mumbai
Passport L-1888952 15.05.2013 Ghaziabad
CDC (National) MUM 187735 11/5/2011 Mumbai
US Visa C1/D

Yellow Fever

Full Name of Next of Kin: Poonam Paliwal Relationship:

Address of Next of Kin: Dwarka Sector 9, Pocket 2 , DDA FLAT NO 123 , New Delhi , Pincode - 110077

Phone :9319206422
Page 1
Height in cms: 178 Weight in Kgs: 68
Boiler Suit Size : XL Shoe Size : 10 INDOS NUMBER
PAN CARD NUMBER CHAPP3415P

Page 2
 Place of
Family Data Name Date of Birth Passport No. Place of Issue
Birth

Wife N/A

Child M/F N/A

Child M/F N/A

Child M/F N/A

Child M/F N/A

Date of
Details of Courses & Certificates Number Date of Issue Issued By
Expiry
Advanced Fire Fighting / AFF R-AFF/B282/15 6/13/2016 6/12/2021 HINDUSTAN INST OF MARITIME TRA
Personal Survival Techniques STR/16/0136 3/14/2016 3/13/2021 AQUATECH INST OF MARINE
Elementary First Aid EFA/16/0178 3/9/2016 UNLIMITED AQUATECH INST OF MARINE
Fire Prevention & Fire Fighting FPR/16/0113 3/14/2016 3/13/2021 AQUATECH INST OF MARINE
Proficiency in Survival Craft & Rescue Boat / RPSCRB/B323/15 6/11/2016 6/10/2021 AQUATECH INST OF MARINE
PSCRB
Medical First Aid/Medicare MA ( R ) 16047 5/31/2016 5/30/2021 APPLIED RESEARCH INSTITUT

Personal Safety & Social Responsibility (PSSR) NO-0100050142011 1/19/2011 TRAINING SHIP RAHAMAN

Radar Observer / ARPA AR 15043 2/20/2015 APPLIED RESEARCH INSTITUT

Radar Simulator / RANSCO RO 15027 2/13/2015 APPLIED RESEARCH INSTITUT
Engine Room Simulator (MGNT LEVEL) N/A
SSO SSO 16123 5/25/2016 APPLIED RESEARCH INSTITUT
STSTD ST-371 10/29/2013 INTERNATIONAL MARITIME I
Bridge Team Management N/A
Ship Handling Simulator N/A
GMDSS D-4936 08.01.2016 3/18/2025 MINISTRY OF COMMUNICAT
GMDSS ENDORSEMENT 67322 4/26/2018 4/25/2023 MINISTRY OF COMMUNICAT
DCE PETROLEUM(Mgmt / Oper) N/A
DCE CHEMICAL(Mgmt / Oper) N/A
DCE GAS (Mgmt / Oper) N/A
OIL TANKER FAMILN (OTF) N/A
TASCO N/A
CHEMICAL TANKER FAMILN (CTF) N/A
CHEMCO N/A
LIQUID GAS TANKER FAMILN (LGTF) N/A
GASCO N/A

Page 3
LCHS N/A
ECDIS ECDIS 15288 9/11/2015 APPLIED RESEARCH INSTITUT
Upgradation of COC (Deck/Eng) courses N/A
Revalidation course for Deck/Engineer Officers N/A
DYNAMIC POSITIONING NOTI/1329/DPBC/055 5/18/2018 NOTI

NAME OF INSTITUTE From To PERCENT Type of Degree

SCHOOL LUTHER COLLEGE 2002 2004- 65% HIGH SCHOOL CERTIFICATE

COLLEGE

ONE YEAR PRE SEA DECK CAD

PRESEA TRAINING SHIP RAHAMAN 8/2/2010 7/5/2011 COURSE

Page 4
Shore Employemnt
From To Rank / Nature Of Work Employer Details
N/A N/A N/A N/A

N/A N/A N/A N/A

Last Two Employers' Name , PIC, and Contact No.

1

Computer Based PMS Experienced N/A

New Construction Experience N/A
Dry Docking Experience N/A

Medical History (Please give details if you have suffered from discease/Previously operated )

NONE

1. Have you ever been denied a foreign Visa

If Yes, state which country and reason (if known)

2. Have you been the subject of a court of enquiry or involved in a Maritime Accident
If Yes please attach details

Declaration

I hereby affirm that all information provided by me in this application is true, factual and to the best of my knowledge and belief and
withheld any information I fully abide by company's rules and terms of employment

Date :_______________________ Signature:_____________________________

Page 5
 FORM NS 01

Photo

1/31/2019
New Delhi
Paliwal
Indian
Vessel (Preferred) OSV
< 6 Months

ector - 9 Pocket 2 DDA FLAT No 123

State Delhi

110077
9319206422
8130463356
@Live.com

Place of Issue Expiry Date

Mumbai 4/1/2023
Ghaziabad 5/14/2023
Mumbai 5/10/2021

MOTHER

Page 6
BMI
09ZL4097

Page 7
 Date of Date of Expiry
Issue

Issued By

HINDUSTAN INST OF MARITIME TRAINING

AQUATECH INST OF MARINE STUDIES

AQUATECH INST OF MARINE STUDIES
AQUATECH INST OF MARINE STUDIES

AQUATECH INST OF MARINE STUDIES

APPLIED RESEARCH INSTITUTE

TRAINING SHIP RAHAMAN

APPLIED RESEARCH INSTITUTE

APPLIED RESEARCH INSTITUTE

APPLIED RESEARCH INSTITUTE

INTERNATIONAL MARITIME INST

MINISTRY OF COMMUNICATIONS
MINISTRY OF COMMUNICATIONS

Page 8
APPLIED RESEARCH INSTITUTE

NOTI

Type of Degree
HIGH SCHOOL CERTIFICATE

ONE YEAR PRE SEA DECK CADET

COURSE

Page 9
 Employer Details

Yes Noü
.

Yes Noü

my knowledge and belief and I have not

___________________

Page 10
Previous Sea Service (Data Commencing from Last Vessel)

Sl. No Name of Owners / Manager Name of Vessel FLAG Year Type GRT TEU Engine Type BHP UMS Rank From
Built Y/N

1 L & T / BIBBY SHIP MANAGEMENT LTS 3000 INDIA 2010 30628 0 6437 CADET 14/02/12
HEAVYLIFT / PIPELAY
2 L & T / BIBBY SHIP MANAGEMENT LTS 3000 INDIA 2010 30628 0 6437 CADET 13/06/12
HEAVYLIFT / PIPELAY
3 L & T / BIBBY SHIP MANAGEMENT LTS 3000 INDIA 2010 30628 0 6437 CADET 07/07/12
HEAVYLIFT / PIPELAY
4 L & T / BIBBY SHIP MANAGEMENT LTS 3000 INDIA 2010 30628 0 6437 CADET 26/10/12
HEAVYLIFT / PIPELAY
5 L & T / BIBBY SHIP MANAGEMENT LTS 3000 INDIA 2010 30628 0 6437 CADET 18/12/12
HEAVYLIFT / PIPELAY
6 L & T / BIBBY SHIP MANAGEMENT LTS 3000 INDIA 2010 30628 0 6437 CADET 19/06/13
HEAVYLIFT / PIPELAY
7 SNP SHIPPING M.V. RESTORER PANAMA 1996 BULK CARRIER 26737 0 11270 CADET 12/03/14

8 TAG OFFSHORE TAG-14 INDIA 2014 OSV 3469 4476 2ND/OFF 23/08/18

10

11

12

13

14

15
16
17
18
19

Page 4
20
21
22
23
24
25

Page 4
 To Months Reason for S/Off

16/05/12 3.1 END OF CONTRACT

21/06/12 0.3 END OF CONTRACT

02/09/12 1.9 END OF CONTRACT

13/11/12 0.6 END OF CONTRACT

20/02/13 2.1 END OF CONTRACT

23/08/13 2.2 END OF CONTRACT

12/01/15 10.2 END OF CONTRACT

05/11/18 2.5 END OF CONTRACT

0.0

0.0

0.0

0.0

0.0

0.0

0.0
0.0
0.0
0.0
0.0

Page 4
0.0
0.0
0.0
0.0
0.0
0.0

Page 4