APPLICATION FORM

1 Position

Position applied for: MARINE ELECTRICAL ENGINEER OFFICER

Are you willing to accept any other positions? NO
If YES, which positions would you consider? -
Readiness From 1ST JANUARY-2018

Personal details
Last Name AHAMMAD First Name NAZIR Middle Name
Date of birth: 01.07.1967 Place of birth PATUAKHALI Nationality BANGLADESHI Blood Group A+
Height 175 CM Weight 75 KG Color of eyes BLACK Color of Hair BLACK
Chest 36’’ Waist 34’’ Collar Inside Lag
National ID 732 423 9230 Boiler Suite XXXL Safety Shoe 43 Cap
Permanent Address: C/O- KAZI ABDUL MANNAN, ‘SHEKUR’, BAT-TALA, NORTH ALEKANDA, BAGURA ROAD,
P.O. # BARISAL SADAR, P.S. # KOTOWALI, DIST # BARISAL, BANGLADESH.
Post code: 8200  Hand Phone No. +880-1721-330 313
Telephone No.: E-Mail ID: Nazirbsl111@gmail.com

3 Education Background
Name From Year To Year Highest Qualification Attained
School KESHABPUR HIGH SCHOOL 1977 1982 S.S.C.
College BARISAL POLYTECHNIC COLLEGE 1985 1990 DIPLOMA IN ELECT. ENG.
Pre Sea Training
Other Qualifications

4 Identity documents
DOCUMENT COUNTRY NUMBER ISSUE DATE PLACE OF ISSUE EXPIRY DATE
Passport: Bangladesh BF 0948156 07.07.2015 DHAKA, BANGLADESH 06.07.2020
Seaman’s book: National C/O/4929 27.03.2007 CHITTAGONG, B’DESH 26.03.2022
Bahamian
Liberian
Panamanian
Other -Norway
Seaman ID (SID) Bangladesh 050004281 09.08.2017 DHAKA ,BANGLADESH. 08.08.2027
Visa – US ‘C1/D’ YES 20162598400007 26.09.2016 DHAKA ,BANGLADESH. 24.09.2021
Other Visa YES/ NO
Yellow Fever Vaccination YES / NO
Holding Australian MCV YES / NO

5 Family details
Next Of Kin / Nominee Marital Status : MARRIED Relationship : WIFE Marriage Date : 09.10.1998
Last Name: AKTER First Name MRS. SALMA
Address: C/O- KAZI ABDUL MANNAN, ‘SHEKUR’, BAT-TALA, NORTH ALEKANDA, BAGURA ROAD,
P.O. # BARISAL SADAR, P.S. # KOTOWALI, DIST # BARISAL, Post code: 8200
 Hand PhoneBANGLADESH.
No. +88 01712 689478 Telephone
Relation Name P.O.B. D.O.B. No. NO.
PPT D.O.I. P.O.I. D.O.E.
WIFE MRS. SALMA AKTER BARISAL 07.12.1973
DTR FATIMA TUZ JUHANA BARISAL 04.10.2001
SON AN NAF I ABDULLAH BARISAL 21.06.2011

Note: Second Next Of Kin / Nominee (In case of voyage with family)
Relation N/A Name
Address:
Mother’s Name
 Hand Phone No. Telephone No.
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6 National Certificate of Competency (Highest certificate of competency held)
Class/Grade Issuing Country Certificate No. Date Issued Place Issued Valid Until
MEEO BANGLADESH BD200674 18.09.2016 DOS, DHAKA 17.09.2021

6a National Dangerous Cargo Endorsements

Endorsement Type Certificate No. Date Issued Place Issued Valid Until
Petroleum
Liquefied Gas
Chemicals

7 Flag State Equivalent Certificates Of Competency issued by other countries (Issued by countries other than in
Section 6)
Class Issuing Country Certificate No. Date Place Issued Valid Until
Liberia Issued
Panama
Bahamas

7a Flag State Equivalent Dangerous Cargo Endorsements (Issued by countries other than in Section 6a)
Country Endorse Type/ Level Certificate No. Date Issued Place Issued Valid Until
Liberia
Marshall Islands
Panama

8 Certificates ( STCW and Value added)

Course Institution Place Issue Date Cert. No. Expiry Date
Basic Safety / Personal Survival- PST IIMT DHAKA 04.09.2016 039,040,041/012135 02.08.2021
Security Awareness Training (SAT) IIMT DHAKA 10.12.2013 BDSAT-2392 09.12.2018
Designated Security Duties - DSD IIMT DHAKA 10.12.2013 BDSTSDSD-1927 09.12.2018
Basic / Advance Fire Fighting – AFF IIMT DHAKA 04.09.2016 045.012140 16.04.2021
Elementary / Medical First Aid- PMFA IIMT DHAKA 04.09.2016 046.012138 11.05.2021
Proficiency In Survival Craft – PSCRB IIMT DHAKA 04.09.2016 043.012142 16.04.2021
Human Relations – PSSR IMTT DHAKA 04.09.2016 042.012139 16.04.2021
Ship Security Officer - SSO IIMT DHAKA 04.09.2016 048.012137 25.04.2021
Tanker Familiarization (Oil,Chem,Gas)
Adv. Oil Tanker Course
Adv. Chemical Tanker Course
Adv. LPG Tanker Course
Bridge & Eng. Room Resource Mgmt IIMT DHAKA 04.09.2016 066.012133 12.09.2021
Shipboard Safety Officer - SBSO
Marine Environment Protection
ISPS Code Familiarization - ISPS
Electronic Chart Display & Info System

2
 9 Record of previous service
9 (Please give a full record starting with the last vessel on which you served)

VESSEL NAME COMPANY# VESSEL FLAG G.R.T. D.W.T. YEAR MAIN ENGINE B.H.P. RANK SIGN ON SIGN OFF DURATION REASON FOR
TYPE OF DATE DATE Y-M-D SIGN OFF
BUILT DD/MM/YYYY DD/MM/YYYY

OCEAN UOSM BULK SINGAPORE 29841 57000 2010 MITSUBISHI 8045 E/OFF 24.01.2017 07.08.2017 00-06-13 NORMAL
PROSPERITY
KOTA BAKAT PIL BULK SINGAPORE 18189 32000 2007 MITSUBISHI 9960 E/OFF 07.10.2016 10.12.2016 00-02-03 F.P.
B&W
KOTA HORMAT PIL CONT. SINGAPORE 13547 1150T. 2007 MITSUBISHI 8600 E/OFF 09.10.2015 06.04.2016 00-05-27 NORMAL
KOBE DIESEL
ATRO-1 SYMPHONY SHIP MGMT BULK TUVALU 23274 42007 1990 SULZER 8600 EOFF 07.03.2014 13.10.2014 00-07-06 NORMAL

BASHUNDHARA-3 SYMPHONY SHIP MGMT BULK BANGLADESH 22531 37722 1985 HITACHI B&W EOFF 29.12.2012 23.06.2013 00-05-25 NORMAL

RATAN FIDELITY RATANPUR SHPG SERV. BULK BANGLADESH 6425 7398 1989 SULZER 3487 EOFF 05.11.2011 24.03.2012 00-04-20 NORMAL

GINGA LEOPARD UNIX LINE PTE LTD. CHEMICAL PANAMA 16222 25982 2008 KOBE DSL 9620 EOFF 24.10.2010 06.02.2011 00-03-13 NORMAL
MITSUBISHI
BRIGHT ROYAL VANGUARD MTM - BD BULK PANAMA 16775 28259 1985 HITACHI B&W 8640 E/OFF 24.01.2010 04.05.2010 00-03-11 FAMILY
PROBLEM
FATEMA JAHAN BRAVE ROYAL SHPG BULK B’DESH 25683 45116 1985 MAN B&W 10880 E/OFF 11.01.2009 03.06.2009 00-05-23 NORMAL

WOQOOF-E- SILVIA SHIPPING G. CARGO PANAMA 16754 27886 1976 MITSUI B&W 11200 E/OFF 18.05.2008 19.10.2008 00-05-00 NORMAL
MUJDALEFA
NORONHA SEA OMCI - GERMANY OIL TNKER M. ISLANDS 4535 7695 2006 NINGBOW CSI 3000 E/OFF 09.02.2008 20.04.2008 00-02-12 2M CONTRACT
SIDRATUL MUNTAHA SILVIA SHIPPING BULK PANAMA 17756 23625 1975 HITACHI B&W 8303 E/OFF 12.09.2007 04.01.2008 00-03-23 NORMAL
MARIS A. K. SHIP MANAGEMENT G. CARGO HONDURAS 20854 35062 1975 MAN B&W 14000 JR/EO 26.04.2007 27.07.2007 00-03-02 NORMAL

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10 For Engineers (Please provide Makers, Model & Capacity details)

Auxiliary Engines

Generators

Cranes / Grabs

Purifiers and Boilers

11 Sailing Experience: (Please advise PRESENT RANK EXPERIENCE on each type of vessel)

CONT/RFG G. CARGO BC/OBO/RR PCC/PCTC OIL/VLCC CHEMICAL PRODUCT LPG/LNG OTHERS TOTAL RANK
(MM-DD) (MM-DD) (MM-DD) (MM-DD) (MM-DD) (MM-DD) (MM-DD) (MM-DD) (MM-DD) EXPERIENCE
58M28D
LAST SALARY DRAWN 4500 USD EXPECTED SALARY 4800 USD

12 References (Please give the name and address of your current or immediate past employer)
Name of company UOSM
Name of person to contact
Address 15 HOE CHIANG ROAD # 22-01 TOWER
FIFTEEN
FIFTEEN, SINGAPORE.
 No. / Facsimile
E-Mail / Web

13 Miscellaneous ( Please give the details of your FC account )

Bank Name DUTCH BANGLA BANK LTD Branch : BARISAL
Account Name NAZIR AHAMMAD
Bank Address 109 SADAR ROAD, BARISAL, BANGLADESH.

Account No. SB A/C; 1271010128200 Swift / BIC Code DBBL BDDH

14 Medical history
Have you ever signed off a ship due to medical reasons? Yes/No NO
Have you undergone any operation in the past? Yes/No NO
Have you consulted a doctor during the last 12 months for an illness/accident? Yes/No NO
Do you have any health or disability problems now? Yes/No NO
(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)

15 Declaration
I hereby declare that the above particulars are true and authorise you to contact the referees listed above.

NAZIR AHAMMAD 27.12.2017

Name/Signature Date