ARCTIC OFFSHORE & MANNING COMPANY PRIVATE LIMITED
DSS. No.3, GROUND FLOOR, SECTOR-1,JAIL LAND, AMBALA CITY- 134003,
HARYANA. TEL .: 91-171-2443181, FAX.: 91-171-2443180, EMAIL.: hparctic@gmail.com
RPSL No:____________
VALIDITY__________
APPLICATION DATE : ____________________
PHOTO
APPLICATION FORM
POSITION : ___________________
ID NO. (FOR OFFICE USE ONLY) : _______
POSITION APPLIED FOR : ____________
AVAILABILITY DATE : __________________
PERSONAL DETAILS :
Name as in Passport
(Surname)
(First name)
(Middle name)
Date/Place of birth
Nationality :
 Tel no.:
Mobile no.:
Email id:
Home address
Mumbai address if any
Mobile no.:
EDUCATION BACKGROUND :
Qualification
School / College
From
To
Percentage / Grade
Institute / College
From
To
Percentage / Grade
TECHNICAL BACKGROUND :
Degree / Diploma
Pre sea training /
Apprentice ship
IDENTITY DOCUMENTS :
Document
Country
Indian
Indian
Seaman book
Other
Do you hold a US Visa ‘C1/D’ ?
Do you hold Schengen Visa
Indos. No. (for Indians only):
Number
Issue date
Expiry date
Place of issue
Passport
Yes / No
Yes / No
Issue date:
Issue date:
Yellow fever:
Union Membership (MUI / NUSI ) :
Expiry date:
Expiry date:
Expiry date:
Expiry date:
FAMILY DETAILS (IF UNMARRIED KINDLY GIVE DETAILS OF FATHER / MOTHER) :
Name
WPIF/1
Relation
D.O.B
PPT No.
Place of issue
01 MAR 2014
Issue date
Expiry date
ECNR
REV 0
NEXT OF KIN DETAILS :
Full name of kin :
Relationship :
 Tel no.:
Address of next of kin :
Mobile no.:
Email id:
CERTIFICATES (HIGHEST CERTIFICATE OF COMPETENCY HELD) :
Grade / Class of COC
Issuing country
Date of passing exam
Certificate no.
DETAILS OF COURSES & CERTIFICATES FOR OFFICERS:
Courses
Certificate no.
Issue date
Placed issued
Expiry date
Issued by
Issue Date
Expiry Date
Issued by
Issue Date
Expiry Date
Advanced Fire Fighting (AFF)
Medical First Aid (MFA) / Medicare
Proficiency in Survival Craft & Rescue Boat
(PSCRB)
Personal Survival & Social Responsibility (PSSR)
SSO (Ship Security Officers Course)
ECDIS
BTM (Renewed every 5 years)
ARPA (Automatic Radar Plotting Aid)
GMDSS
Radar Observer / RANSCO Simulator
GMDSS Endorsement
Oil Tanker Familiarization (OTFC) / TASCO
DCE Oil – Support / Operation / Management
Chemical Tanker Familiarization (CTFC) /
CHEMCO
DCE Chemical – Support / Operation /
Management
Specialized Training Programme On Oil Tanker
Operations (STPOTO)
Framo Course
Revalidation Course for Deck / Engine Officers
Refresher & Up Gradation Course for Deck /
Engine Officers
DETAILS OF COURSES & CERTIFICATES FOR RATINGS:
Courses
Certificate no.
FIRE PREVENTION & FIRE FIGHTING (FPFF)
ELEMENTARY FIRST AID (EFA)
Personal Survival Technique (PST)
Personal Survival & Social Responsibility (PSSR)
ISPS Course
Oil Tanker Familiarization (OTFC)
DCE Oil – Support
Chemical Tanker Familiarization (CTFC)
DCE Chemical – Support
AB / MM Course
Watch Keeping Certificate Ratings
(Deck/Engine)
Pump Man Course
Cookery Course
MMD Cookery Certificate
Fitter Course / Class Cert.
WPIF/1
01 MAR 2014
REV 0
OTHERS :
ISPS Course
Ship Safety Officers Course / Risk Assessment
Ship Maneuvring Simulator
BRM / MRM / BERM (Renewed every 5 years)
Electrical/Electronics for Marine Engineers –
Basic / Advance
FOR ENGINEERS (PLEASE PROVIDE DETAILS) :
Generators
Boilers
Cranes
Framo ( No. of vessels )
TOTAL SAILING EXPERIENCE
Crude Tankers
Product Tankers
Chemical Tankers
Oil / Chemical
Others
MEDICAL HISTORY (IF THE ANSWER IS YES TO ANY OF THE BELOW, PLEASE GIVE FULL DETAILS AND ATTACH A
SEPARATE PAGE IF NECESSARY) :
Have you ever signed off a ship due to medical reasons ?
Have you undergone any Surgery / Accident
Do you have any health disability problems now ?
Yes / No
Yes / No
Yes / No
GENERAL :
Have you ever been the subject of a court of enquiry or involved in a maritime accident ?
Have you ever had a professional license suspended or revoked ?
Do you have any pending criminal inquiry
Yes / No
Yes / No
Yes / No
BANK ACCOUNT DETAILS :
Account Holder’s Name :
Name of bank & account no. :
Branch & address :
BOILER SUIT SIZE : ______________________
SAFETY SHOE SIZE : ______________________
DECLARATION :
I hereby affirm that all the information provided by me in this application is true and correct .
___________________
Applicant’s Signature
___________
Date
FOR OFFICE USE ONLY :
Interviewed on _________________ found
Checked on __________ with Mr/Ms ________________
rep. of ____________________ (Last employer) &
received satisfactory/unsatisfactory report regarding his
professional experience & attitude.
By ________________________
WPIF/1
satisfactory/unsatisfactory.
By______________________
01 MAR 2014
REV 0
RECORD OF PREVIOUS SERVICE ( KINDLY START FROM YOUR FIST SHIP ):
Company
WPIF/1
Vessel Name
Vessel Type
DWT /
GRT
01 MAR 2014
Year
Built
Type of Engine
(Please give full details)
BHP
Rank
Sign on
(dd/mm/yy)
REV 0
Sign Off
(dd/mm/yy)
Duration
(dd/mm/yy)
Reason for Sign
off