Application

[PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM]

1. Personal Data
First Name RAJKUMAR Middle Name (s) CHANDRAKANT Last Name / Surname MADANALLI

Nationality (or current Citizenship ) INDIAN Marital Status1: UNMARRIED

Country of Origin INDIAN

Date of Birth: 01/06/87

(DD / MM / YY)

Place / City of Birth MADANHALLI,KARNATKA ,INDIA

Religion: HINDUMale LINGAYAT Female 1 Select from: Single Married Divorced Common Law Partner Widowed Separated Gender : Rank applied for: CADET Willing to accept lower rank? Yes No Available From (date):
(DD / MM / YY)

07/03/2012

Primary / Permanent Address: AT-POST:KEGAON(BK),TAL-AKKALKOT,DIST-SOLAPUR

Alternative / Temporary Address:

Until: ____ / ____ / ___

City: SOLAPUR State: MAHARASHTRA Nearest Airport :MUMBAI Mobile Tel. (+91)9209060848,9975910223 Contact Method : Collar:40cm Email

Post Code: 413215 Country : INDIA Home Tel: Fax: Fax

City: State: Phone: Email:RAJMADANOLI 505@GMAIL.COM Mobile Phone Cap:

Post Code: Country:

Home Phone

Post

Chest:97cm

Waist:34 inch Inside Leg: Sweater size: XL

Specify size as S, M, L, XL, XXL for : 2. Personal ID / Documents / Visa Type of Document / ID 1 Seamans Book (National)

Boiler suit size: XL

Shoe Size:M

Country of Issue

No.

Date of Issue (DD / MM / YY)

Issued at (Place)

Valid Until (DD / MM / YY)

REPUBLIC OF LIBERIA

1025316

12/01/12

OFFICE OF DEPUTY COMMISSIONER OF MARITIME AFFAIRS,R.L. VIENNA,VIRGINIA, U.S.A NAGPUR,INDIA

12/07/13

Passport US Visa C1/D

REPUBLIC OF INDIA Yellow

J9287497

23/06/11

22/06/21

Vaccination Fever
Typhoid HIV Drug & Alcohol

GIVE TAX INFORMATION BELOW ONLY IF REQUESTED TO DO SO

Social Security

Personal Tax

Number:

Issuing Country

Number:

Issuing Country:

3.Nominee / Next of Kin & Family Details Full Name of Nominee for compensation in case of fatality: SANJAY CHANDRAKANT MADNOLI City: SOLAPUR Email:SANJAYONGAMIL@GMAIL.COM
1

Relationship1 BROTHER

Gender : Male Female

Nationality :INDIAN

Address:AT-POST:KEGAON(BK),TAL-AKKALKOT,DIST-SOLAPUR Post Code: 413215 Tel: Country: INDIAN Mobile: (+91)-9209060848

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

Family Data:
Relationship Spouse / Partner2 Child Child Child Child Child
2

First Name F F F F F

Last Name

Date of Birth

Passport No.

Issued

Place

Valid Until

M M M M M

Indicate type of valid visa3 Strike out inapplicable item

3

USA

Canada

Brazil

Schengen

UK

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.) Date of Date of Description of Cert / Country of Issue Expiry Place of Number Course Issue (DD-MM(DD-MMIssue YY) YY)

Issuing Authority / Body

(A) Reg I Personal Training Record Reg I/14 Medical Fitness Cert Reg I/9 (B) Reg VI / 1 Basic Safety Training

Personal Survival Techniques Elementary First Aid Fire Fighting & Fire Prevention Personal Safety & Social Resp. (C)

INDIA INDIA INDIA INDIA

CAA/PST/2455/2011 CAA/EFA/2201/2011 CAA/FPFF/1201/2011 CAA/PSSR/1944/2011

25/08/11 14/09/11 13/08/11 10/09/11

SECUNDERABAD SECUNDERABAD SECUNDERABAD SECUNDERABAD

DG SHIPPING, GOVERMENT OF INDIA DG SHIPPING, GOVERMENT OF INDIA DG SHIPPING, GOVERMENT OF INDIA DG SHIPPING, GOVERMENT OF INDIA

Reg VI / 2 4 Additional Training

Proficiency in Survival Craft & Rescue Boat Fast Rescue Boats Advanced Fire Fighting Medical First Aid Medical Care (Master / C/O) (D)
4

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

Certificate of competency Endorsement chem)

Endorsement national(Oilchem)

(Oil-

Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you

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.

(E)

Other mandatory/recommended Certificates / Courses (as applicable)

ARPA (Reg II/1 + Solas) Radar Simulator English Language Bridge Team / Resource Mgmt Hazmat (US 49CFR) Ship handling/Ship Manoeuvring Simulator Shipboard Security Officer Navigation and watch keeping

Description of Cert / Course

Country of Issue

Number

Date of Issue (DD-MMYY)

Date of Expiry (DD-MMYY)

Place of Issue

Issuing Authority / Body

(F)

GMDSS Certificates (including flag state endorsements)

GMDSS (Main Issuing Authority) GMDSS endorsement GMDSS (Flag State) GMDSS (Flag State) GMDSS (Flag State) GMDSS (Flag State) (G) Reg V / 1 Special Requirement for Tankers Level1: Country Description Incharge of Issue Level2: Asst. Endorsement Oil Endorsement Chemical Endorsement Gas Tanker Familiarisation Tanker Familiarisation Tanker Familiarisation Special Tanker Safety Special Tanker Safety Special Tanker Safety (Oil) (Chemical) (Gas) (Oil) (Chemical) (Gas) Para 1 Para 1 Para 1 Para 2 Para 2 Para 2 Date of Issue (DD-MMPlace of Issue Issuing Authority / Body

Number

(H)

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

Issuing Authority / Body

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

Blood Type: B+

(1)

Use only the following abbreviations for vsl types: ABRVTN GC MP CN BC SB TB TYPE OF VSL CHEMICAL TANKER PRODUCT TANKER OIL TANKER VERY LARGE CRUDE CARRIER SELF PROPELLED BARGE HARBOUR TUG ABRVTN CT PT OT VLCC SPB HT TYPE OF VSL OIL & BULK ANCHOR HANDLING DYNAMIC POSITION SURVEY VESSEL TUG PASSENGER VESSEL ABRVTN OBO AHTS DP SV TG PV TYPE OF VSL ULTRA LARGE CRUDE CARRIER STORAGE TANKER FIXED STORAGE BUNKER BARGE CREW BOAT CRUISE VESSEL ABRVTN ULCC ST FSO BB CB CV

TYPE OF VSL GENERAL CARGO MULTI PURPOSE CONTAINER BULK CARRIER SUPPLY BOAT TUG & BARGE

6. Medical History: 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. (A) Have you ever signed off a ship due to medical reasons? Name of vessel Brief description of illness/injury/accident Date of occurrence Yes No Place of occurrence If yes, please provide following details (If space is insufficient, attach additional sheets) :

(B)

Have you undergone any operation in the past? If yes, please provide following details: Date

Yes

No Present condition

Details of operation

Period of disability

(C)

For what illnesses or accidents have you consulted a doctor during the last 12 months? Date Therapy/Treatment

Details of illness / accident Nil

(D) Please give details of any health or disability problem Details: nil

7.

Bank/Pension Scheme Details: M.N.O.P.F. Membership No. National Ins.No. A.V.C.

Bank Name: STATE BANK OF INDIA Address: AT-POST:TADVAL,AKKALKOT,DIST-SOLAPUR Account Name: SAVING ACCOUNT Account No.:30575507647 Sort Code:(BRANCH CODE):4653 8. General Yes

(A) Have you ever been denied a foreign visa? If yes, state which country and reason (if known) (B) (C)

No Yes No

Have you been the subject of a court of enquiry or involved in a maritime accident? If yes, please attach details Give details below of two recent employers who we may contact for references: Reference 1 Reference 2

Name of Company Name of person to contact Address Country

Telephone /mail

Place: ............................. Date: /.............../ 2011. Signature:.......................................................................... For Office Use: