V.

SHIPS MANAGEMENT SYSTEM (VMS)

Application Form
[PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM] Individuals Code Number

1. Personal Data
First Name KAUSHIK Middle Name (s) Last Name / Surname BASU
AFFIX YOUR RECENT PASSPORT SIZE PHOTOGRAPH HERE (Attach separately if filing electronically)

Nationality (or current Citizenship ) Indian Marital Status1: Married

Country of Origin INDIA

Date of Birth: 19 / 11 / 75
(DD / MM / YY)

Place / City of Birth Kolkata

Religion: Gender : Male HINDU Female 1 Select from : Single Married Divorced Common Law Partner Widowed Separated Rank applied for: Chief Officer Primary / Permanent Address: Anandamoyee Appertment 8/15 Nilkantha Chatterjee Street; Belghoria. City: Kolkata State: West Bengal Nearest Airport : Dum Dum Mobile Tel. 9830259210 Contact Method : Collar:
cm

Willing to accept lower rank? Yes No

Available From (date): _20 / 06 / 10

(DD / MM / YY)

Alternative / Temporary Address:

Until: __ / __ / _

SAME AS PERMANENT ADDRESS City: State: Phone: Email: Mobile Phone Home Phone Cap: cm Shoe Size: Post Post Code: Country: Post Code: 700056 Country : India Home Tel: 913325442776 Fax: Fax

Email Chest: cm

Waist: cm

Inside Leg: cm

Specify size as S, M, L, XL, XXL for :

Sweater size: Boilersuit size:

2.

Personal ID / Documents / Visa

Type of Document / ID 1 Country of Issue No. Date of Issue (DD / MM / YY) Issued at (Place) Valid Until (DD / MM / YY)

Seamans Book (National) Passport US Visa C1/D National Seaman ID Yellow fever Australia MCV

INDIA INDIA INDIA INDIA

CL 46722 G0894211 91859462 BATCH NO. 1562

03 / 03 / 00 28 / 03 / 07 04 / 04 / 08 / / 24 / 05 / 02 / / / / / /

KOLKATA KOLKATA KOLKATA KOLKATA

18 / 05 / 15 27 / 03 / 17 02 / 04 / 13 / / 23 / 05 / 12 / / / / / /

GIVE TAX INFORMATION BELOW ONLY IF REQUESTED TO DO SO

Social Security
Number: Issuing Country Number: AHMPB8510D

Personal Tax
Issuing Country: INDIA

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V.SHIPS MANAGEMENT SYSTEM (VMS)

3.Nominee / Next of Kin & Family Details
Full Name of Nominee for compensation in case of fatality: Nationality : INDIAN Female PAYEL BASU Address: ANANDAMOYEE APPERTMENT; 8/15 NILKANTHA CHATTERJEE STREET; BELGHORIA. City: KOLKATA Post Code: 700056 Country: INDIA Email: Tel: 913325442776 Mobile: 9836023810 Spouse
1

Relationship1

Gender : Male

Select From : Spouse Partner Child Parent Grand Parent Other Relative (Please Specify)

Family Data:
Relationship Spouse Child Child Child Child Child
2

First Name
2

Last Name

Date of Birth

Passport No.

Issued

Place

Valid Until

/ Partner M M M M M F F F F F

PAYEL ISHAN
3

BASU BASU
USA

28 / 01 / 81 18 / 11 / 07 / / / / / / / /
Canada

H1202879 G8207402

INDIA INDIA
UK

KOLKATA KOLKATA

03 / 11 / 18 25 / 05 / 13 / / / / / / / /

Indicate type of valid visa3 Strike out inapplicable item

Brazil

Schengen

Other

Please consider period on board

4. STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications: (Add separate sheet if data exceeds space available.) Country of Issue Number Description of Cert / Course (A) Reg I Personal Training Record Reg I/14 Medical Fitness Cert Reg I/9 Date of Issue (DD-MMYY) Date of Expiry (DD-MMYY) Place of Issue Issuing Authority / Body

/ / / / 29 / 01 / 00 09 / 02 / 00 11 / 12 / 97 05 / 02 / 00 17 / 05 / 02 / / 08 / 06 / 01 15 / 03 / 01 30 / 11 / 06

/ / / / / / / / / / / / / / / / / / / / / /

KOLKATA KOLKATA KOLKATA KOLKATA KOLKATA KOLKATA KOLKATA KOLKATA

DGS DGS DGS DGS INDIA INDIA INDIA INDIA

(B) Reg VI / 1 Basic Safety Training INDIA SMC/PST/569 Personal Survival Techniques Elementary First Aid Fire Fighting & Fire Prevention Personal Safety & Social

Resp. (C) Reg VI / 2 4 Additional Training Proficiency in Survival Craft & Rescue INDIA 01779 Boat Fast Rescue Boats Advanced Fire Fighting Medical First Aid Medical Care (Master / C/O)

INDIA INDIA INDIA

SMC/EFA/259 083/97 SMC/PSSR/1173

INDIA INDIA INDIA

09352 MFA0110100591 249

DGS INDIA DGS INDIA DGS INDIA DGS INDIA

(D)
4

Reg II / 1-4, III / 1-4 Officers Certificate of Competency & Ratings Watch-keeping Certificate (including flag state endorsements)

MASTER (F.G)
4

INDIA

IFOO10312

03 / 05 / 10 / / / / / / / / / /

05 / 04 / 15 / / / / / / / / / /

KOLKATA

GOVT.0F INDIA

Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you Other mandatory/recommended Certificates / Courses (as applicable) INDIA L/26/07 ARPA (Reg II/1 + Solas) 26 / 04 / 02 / / INDIA K/20/03 Radar Simulator 21 / 04 / 02 / / English Language Bridge Team / Resource Mgmnt Hazmat (US 49CFR)

(E)

INDIA

Q/32/01

/ / 21 / 04 / 05 / /

/ / / / / /

KOLKATA KOLKATA KOLKATA

DGS INDIA DGS INDIA SENSEA MARITIME ACADEMY

Select as applicable: Passport Seamans Book Seaman Passport Seafarers Identity Document Registration Book National ID Card PAG-IBIG Housing Insurance Health Insurance Overseas Emp Cert PHL Card Pension Fund Provident Trust Professional Organisation Driving Licence Visa Vaccination Yellow Fever.

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V.SHIPS MANAGEMENT SYSTEM (VMS)

Shiphandling /ShipManoeuvring Simulator Shipboard Security Officer ECDIS

INDIA INDIA INDIA

SMS/B55/08 00761 050

19 / 02 / 10 13 / 04 / 05 17 / 04 / 08 / / / /
Date of Issue (DD-MMYY)

/ / / / / / / / / /
Date of Expiry (DD-MMYY)

CHENNAI KOLKATA CHENNAI

DGS INDIA DGS INDIA IMC CHENNAI

Description of Cert / Course

Country of Issue

Number

Place of Issue

Issuing Authority / Body

(F)

GMDSS Certificates (including flag state endorsements) GMDSS (Main Issuing INDIA GOC9071 07 / 02 / 02 Authority) INDIA GOC/MMD/KOL/03643 09 / 04 / 07 GMDSS (Flag State) GMDSS (Flag State) / / GMDSS (Flag State) GMDSS (Flag State) GMDSS (Flag State)

/ / / / / /

06 / 02 / 12 06 / 02 / 12 / / / / / / / /

NEW DELHI KOLKA TA

GOVT. OF INDIA DGS INDIA

Issuing Authority / Body DGS INDIA

(G)

Reg V / 1 Special Requirement for Tankers Country Level1:Asst Description Number Level2:Incharge of Issue Endorsement Oil Endorsement Chem I/II Endorsement Chem III Endorsement Gas Tanker Familiarisation 1 Tanker Familiarisation 1 Tanker Familiarisation

LEVEL 2
Para Para 1 (Chemical) Para

(Oil) (Gas)

Special Tanker Safety (Oil) Para 2 Special Tanker Safety (Chemical) Para 2 Special Tanker Safety (Gas) Para 2

INDIA INDIA

DC/D/KOL/0509 6 41/1744/00237

09 / 05 / 08 / / / / / / / / / / / / 25 / 07 / 02 / / / /

Date of Issue (DD-MM-

08 / 05 / 13 / / / / / / / / / / / / / / / / / /

Date of Expiry (DD-MM-

Place of Issue

KOLKATA KOLKATA

DGS INDIA

(H) V/2 and V/3 Special requirement for Passenger / Ro-Ro Passenger Vessels Vsl Type Date of Country of Place of Number -Pax / Issue Issue Issue RoRoPax (DD-MM Crowd Management Description Crisis Mgmnt & Human Behaviour Pax Safety, Cargo Safety & Hull Integrity Pax Safety Familiarisation Training Safety Training

Issuing Authority / Body

RoPax

/ / / / / / / / / / / /

5. Sea Experience : (Last 5 years; Start the listing below with the most recent experience)
Company Flag & Vessel Name Type
(1)

GRT

DWT

Main Engine

(2)

BHP

Rank

Date Date To From dd/mm/yy dd/mm/yy

INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP
(1)

INDIAN/RATNA PUJA INDIAN/RATNA URVI INDIAN/RATNA URVI INDIAN/RATNA PUJA INDIAN/RATNA URVI INDIAN/RATNA URVI INDIAN/RATNA SHALINI

TNC TNC TNC TNC TNC TNC TNC

58446 54980 54980 58446 54980 54980 55178

104560 98400 98400 104560 98400 98400 98570

18420 13800 13800 18420 13800 13800 12950

CH.OF F CH.OF F CH.OF F 2/0 2/0 2/0 2/O

07/05 / 09 27/02 / 09 17/05 / 08 15/08 / 07 18/05 / 07 29/06 / 05 31/12 / 03 / / / / / / / / / /

17 / 11 / 09 28 / 04 / 09 06 / 11 / 08 26 / 10 / 07 13 / 08 / 07 26 / 01 / 06 16 / 12 / 04 / / / / / / / / / /

Use only the following abbreviations for vsl types:

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V.SHIPS MANAGEMENT SYSTEM (VMS)

B/C CO CH CH DR DP FS FS
(2)

Bulk Carrier Cellular Chem Carrier Chem Carrier Dredgers Dynamic Fishing Vsl FloatingStorage

FPS GC HLV LSH LIV LNG LOG LPG

FloatgProdStor General Cargo Heavy Lift Vsl Lash Live Stock LNG Carrier Log/Timber LPG Carrier

ML MS NV RIG OS OB O/ OT

Multi-purpose MultiServiceVes Naval Ship OffShore Oil Rig OffShore Supply Ore/Bulk/OilCarr Ore/OilCarrier Other

PA RF R/R PR SA SR SU TU

Passenger Reefer Ro/Ro RoRo-Pax Sailing Vsl Survey SelfTug

YAT TNB TNC TNP TNS TNV

Yacht Tanker(Bitume Tanker(Crude) Tanker(Produc Tanker(Storag Tanker(VLCC/ULC

Engineers to give make/model of engines, e.g. MAN 14V52/55A or SULZER 5RTA58

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V.SHIPS MANAGEMENT SYSTEM (VMS)

6. Medical History:
Sheet 4 All previous illnesses other than minor afflictions should be stated below or updated. If not previously disclosed, the Company is entitled to refuse any reimbursement of medical costs, claim for treatment or for any other insured benefits. Blood Type: O+ (A) Have you ever signed off a ship due to medical reasons? Yes No If yes, please provide following details (If space is insufficient, attach additional sheets) :
Name of vessel Date of occurrence Place of occurrence

Brief description of illness/injury/accident

/ /

(B) Have you undergone any operation in the past? If yes, please provide following details:
Details of operation Date

Yes

No
Present condition

Period of disability

Details of illness / accident

/ / / / / /
Date

Therapy/Treatment

(C) For what illnesses or accidents have you consulted a doctor during the last 12 months? N/A
Details:

/ / / / / /

(D) Please give details of any health or disability problem N/A

7.

Bank Details:

Other Details: (if any)

Bank Name HSBC Address FORTTERROZO RAMANI CHATTERJEE ROAD;

GARIAHAT;; KOLKATA; INDIA Account Name SAVINGS ACCOUNT Account No. 023 382237 006 Sort Code

8.

General

(A) Have you ever been denied a foreign visa? Yes No If yes, state which country and reason (if known) (B) Have you been the subject of a court of enquiry or involved in a maritime accident? If yes, please attach details (C) Give details below of two recent employers who we may contact for references:
Reference 1 Name of Company Name of person to contact Address

Yes

No

Reference 2

Country Telephone

INDIA STEAMSHIP MR. AMIT BASAK 44, PARK KOLKATA; INDIA. INDIA 9836310011

STREET;

I hereby declare that the above, including Medical History, is true. I further consent to the holding and processing by you and any of your direct or indirect parent or subsidiary or associated or affiliated companies (V Ships) and your or V Ships principals of personal data about me (including where appropriate data concerning racial or ethnic origin, religious beliefs, membership of a trade union, physical or mental health or condition, commission or alleged commission of an offence and the proceedings and the outcome of any proceedings relating thereto) for all purposes related to my application for employment on board vessels managed by V Ships or vessels owned or operated by third parties for whom V Ships is engaged to provide crew. I understand that this data will be stored in your databases in relation to my actual or potential employment by or through V Ships. Further, I confirm that the above may involve the transfer of my personal data within V Ships or to third parties worldwide.

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V.SHIPS MANAGEMENT SYSTEM (VMS)

Place: FOR OFFICE USE: Date / / Signature: ...

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Chapter 14 CRW13 Application Form File Ref: Office File: 11B Revision Number: 02