APPLICATION FORM

Pacific
SECTION I
Internati
onal
Applicant
Lines Name KOSMO PATABANDIGE THUSITHA DALPATHADU
( As
PTEper
) passport )
LTD Applied
Rank 2nd Engineer
140 Cecil Street. #03-00 PIL Building
Singapore
Date 069540
of Availability
17.02.2017
SECTION II Personal Details

Family Name/Surname
Dalpathadu
First Name/Given Name Kosmo Patabandige Thusitha

Date of Birth 25.09.1980 Place of Birth :Mathara

(less than 18 yrs not eligible to apply)
Nationality
Sri Lankan
Marital / Civil Status
Single X Married Divorced Separated
INDOS No(for Indians)

Permanent Address 270/D, Gangarama Road, Thumbovila, Piliyandala

Present Address
(if different from permanent add)
Home Principal Airport Bandaranayake International Airport

Contact Number
Tel +94778252569
Mobile +94778252569
Email thusitha.dalpathadu@gmail.com Skype ID: tdalpathadu
Height (in cms) 178 Weight (in kgs): 75
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Boiler Suit Size XL Shoe Size: 9”

SECTION III Travel Documents

Doc Number Issue Date Place of Issue Expiry Date

Passport N5379875 22.01.2015 Colombo 22.01.2025

Seaman Book C027381 21.04.2005 Colombo 18.04.2020
USA Visa C1/D H7629704 04.05.2016 Colombo 02.05.2021
Aust MCV
Yellow Fever A5285-4 17.07.2007 Colombo 17.07.2017
SECTION IV Pre-Sea Training / Apprenticeship Details
Name of Institute From To Type of Degree/Certification Obtained
University of Moratuwa 2001 JAN 2004 DEC Diploma in Marine Engineering

SECTION V Certificate of Competency Held (valid)

Class / Grade Issuing Country Certificate No Date Issued Expiry Date

Class 2 Sri Lanka EN/2/0168 19.02.2004 11.02.2019

SECTION VI Certificate of Endorsement Held (valid)

Class / Grade Issuing Country Certificate No Date Issued Expiry Date

SECTION VII Courses Attended and Certificates Obtained

Name of Course/Certificate Institute Place Issue Date Certificate No. Expiry Date
Advanced Fire Fighting MSTI-Colombo Colombo 06.01.2017 C2017/01/06/122/01/00
Proficiency in survival craft MSTI-Colombo Colombo 05.01.2017 C2017/01/05/121/01/01
Medical First Aid MSTI-Colombo Colombo 07.01.2017 C2017/01/07/119/01/01

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Basic refresher & upgrade MSTI-Colombo Colombo 11.01.2017 C2017/01/09/116:120/02/00
SDSD LANKA ACADEMY Panadura 11.03.2014 LATS-SDSD-1424
SSO LANKA ACADEMY Panadura 07.02.2015 LATS-SSOC-1928
Maritime English-Mgt. level CINEC Malabe 14.11.2013 LC-0818/007/0074
ER Simulator-Mgt. level CINEC Malabe 03.02.2014 MS-0401/010/0033

SECTION VIII Medical History

Yes No
Have I ever signed off a ship due medical reason ? X
Have I undergone any medical operations in the past ? X
Have I consulted a doctor during the past 12 months for an illness / accident ? X
Do you have any health or disability problems now ? X
If answer to any of the above is YES then give further details below or on a separate sheet of paper

Name of Applicant: K.P.T.Dalpathadu

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 Vessel Name Company Vessel GRT TEU(Co Engine BHP Rank S/on Date S/off Date Remarks
Type ntr) Make &Type (For short
(in full) tours)
MV BBC MAHAWELI Lanka Maritime Gen. MANB&W6S 2E
Services Cargo 9722 46MC 10540 17.05.2016 22.10.2016
MV DANIEL N Anglo Eastern VLOC MANB&W6S 2E Urgent,family
151448 80MC 30440 08.02.2016 09.04.2016 matter
MV MARGOT N Anglo Eastern VLOC MANB&W6S 2E
144759 80MC 24280 27.03.2015 28.10.2015
MV AVANTGARDE Lanka Maritime AHTS WICHMANN 2E
Services 1732 5AXAG 5888 05.06.2014 23.12.2014
MV CAPRICORN Lanka Maritime AHTS WARTSILA 3E Promoted &
Services 1413 VAASA V32 11140 26.03.2014 30.05.2014 Transferred
MV LANKA Ceylon Shipping Gen. SULZER 3E
MAHAPOLA Corporation Cargo 8082 6RLB 56 7563 19.12.2011 14.06.2012
MV CEB PCPP T-2 Ceylon Shipping Tug CUMMINS CE
Corporation 260 KTA 32 2400 13.11.2010 12.07.2011
MV KOTA ABADI PIL Container MAN B&W 3E
16430 6L67GB 14885 29.09.2009 28.02.2010
MV GAZZLE COAST Consort Express Gen. MAK 6M551 2E
Lines Cargo 4292 2800 27.12.2008 24.03.2009
MV MERCS MIRISSA Mercmarine Gen. MAN DMR 3E
Cargo 10970 K8Z 70 11063 05.06.2008 31.10.2008
MV ORIENT STRIDE Mercmarine Container MAN 6K 3E Management
16100 SZ70 13470 21.12.2007 03.04.2008 Change
Name of Applicant: K.P.T.Dalpathadu

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SECTION IX GENERAL
Yes No
Have I ever been the subject of a court of enquiry or involved in a maritime X
accident ?
Have I ever had a professional licence suspended or revoked X
If yes to any of the above then please give full details below or on a separate sheet of
paper

Any other information you wish to add in support of your application

Family Data (Spouse & Children only)

Sr First Name Relationship Date of Birth
No
01 Inoka Weerasinghe Spouse 15.05.1983

02 Yumeth Dalpathadu Son 22.04.2011

Minimum 2 references of name of person in charge with designation and contact

in 2 previous companies
Name of Name of Person in Charge Designation Contact Details
Company
Lanka Mrs. Harshi Jayakody Crew Manager
maritime serv.
Anglo Eastern Mr. Chanaka Liyanage Crew Manager

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Declaration :

I confirm that the validity of all above mentioned documents covers the contract duration + 3
months and + 6 months for passport .

I hereby certify that the information given in my application form including sea service details are
true and complete to the best of my knowledge. I agree my understanding that if employed by
PIL, any false or incomplete statement on this application and submitted document will lead to my
dismissal from the employment without notice or pay-in-lieu.

Name of Applicant:

Signed :____________

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