Hotel Job Application Form

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					                               UNITED                      OCEAN                                                   file 101 Rev 5 09/07       DE 27

           SHIP MANAGEMENT PTE LTD, SINGAPORE                                                                    Application form no :
     LICENSE NO: RPSL-040                               Date of Expiry : 17.10.2011
Mumbai :- 701-702, The Qube, Off.Sahar International Airport Approach Road, Plot
No.1498, A/2, Andheri (E), Mumbai-400 059. Tel:-(91) 22 28565656/57                      Fax:28565670
E-mail: mumbai@unitedocean.com.sg
New                      506 Mercantile House, 15, Kasturba Gandhi Marg New Delhi - 110 001                           Passport Size Photo ,
Delhi:                   Tel:- (91) 11 2335 0267/ 2335 0268                  Fax:- (91) 11 5151 0293                     Matt finish with
                         E-mail:            delhi@unitedocean.com.sg                                                   White back ground

              APPLICATION FORM for OFFICERS
POSITION APPLIED FOR………………………………
Date Applied:-……………………..                  Date of Availability:……………………

 1   Surname:                                                  First                                    Middle
     (As per Passport)

 2   Date of Birth                        Place (City and Country)                                               Nationality
     (As per Passport)

 3   Height in cm                           Weight                                               Blood Group

 4   Passport No :                       Place of Issue                           Issue Date:                     Expiry Date:

     ECNR                                      U.S. Visa Issue Date                                               Expiry Date:

 5   Yellow Fever ( D O E)                                                      Indos No:-

 6   Permanent Address

                                                                                      Phone :

 7   Present Address

                                                                                      Phone :

 8   Marital Status               Single / Married                                            No. of Children:

 9   Next of Kin                                                                                   Relation

10 LICENCE / CERTIFICATE OF COMPETENCY
                                                                                                                    Date of
                                             Grade           Number           Date of Issue         Date of        Passing /          * Limitation
                                                                                                    Expiry        Revalidation
     INDIAN

     UK / AUSTRALIA

     PANAMA /

     OTHER /
     Limitation : Confirm STCW 95 compliance & no restriction on tonnage for deck Officers or BHP/Motor/Steam for Engineers.
11 Seaman Book ( S I B )                    Number        Date of Issue               Date of Expiry                       Place of Issue
     Indian

     Panamanian

     Other

     Acknowledgement:                        Received copy of this application.

                         Candidate signature…………………………………. Date……………………….
12 STCW Certificates                   Number       Date of Issue     Date of Expiry         Place of Issue            Issued by
     Advance Fire Fighting

     Proficiency in Survival Craft &
     Rescue Boat
     Personal Safety & Social
     Responsibility (PSSR)
     Medical First Aid at Sea/ Ship
     Captain's Medicare

     GMDSS (Indian / UK )


     GMDSS Endorsement


     RANSCO

     Bridge Team Management Ship
     Manouvering Simulator

     Engine Room Simulator (ERS)

     Tanker Safety Course
     (Petroleum/Chemical/LPG)
     Dangerous Cargo Endorsement
     (Petroleum/Chemical/LPG)

     Refresher and updating Course


     Ship Security Officer


13 PRE-SEA TRAINING
     Name of Institute / Collage             Town / Place                 From              To                Type of Degree




14 ACADEMIC QUALIFICATION
     Name of Institute / College             Town / Place                 From              To                Type of Degree




15 HEALTH DECLARATION : False declaration will result in termination of services and recovery of all medical and
    repatriation expenses incurred by the company, and all claims by the seafarer or his next of kin, for treatment or
    compensation will be deemed Null and Void..
                                                                                                       YES             NO
a ) Did you suffer, or do you presently suffer, from any disease likely to render you until for
    services at sea or Likely to endanger the health of other persons on board:
b)   Did you suffer any accident which rendered you temporarily and /or partly disabled :
c)   Did you ever undergo Psychiatric Treatment or electric shock treatment:
d)   Are you addicted to alcohol or drug of any kind. If yes, please give details:
e)   Do you presently suffer from Diabetes, High BP or Low BP problems or epilepsy ?
f)   Have you sufferred any Bone Fractures in the past three years ?
g)   Do you have any metal plate, or screws within your body or any artificial limbs in use ?
h)   Additional Information from Applicant, concerning disclosure of his medical History
16 PREVIOUS SEA SERVICES : (Data Commencing from Last Vessel Served)
                                                                             Type of                                 From        To       Total
    Name of Owners / Managers         Name of Vessel      Type of Engine     Vessel    DWT/GRT     BHP      RANK   dd/mm/yy   dd/mm/yy   mm/dd
a
b
c
d
e
f
g
h
I
j
    # Electrical Officer to mention UMS Experience


17 CARGOES CARRIED

    TRADE PATTERN

    NATIONALITY SAILED WITH
                                                                           SELF
    CARGO GEAR                   CRANE                 PUMPS               UNLOADER              CONVEYOR          GANTRY     GRABS

    COMPUTER SKILL                       YES / NO      AMOS                MS WORD               EXCEL             OTHER

    MISCELLANEOUS                DRY DOCKS NOS                             NEW BUILDING TAKEOVER         PREPARATION FOR PSC / USCG / AMSA

    PREPARATION FOR QMS / ISM / ISPS


    LAST WAGES DRAWN

    REASON FOR LEAVING LAST EMPLOYER


    REMARKS FOR OFFICE USE
 18 REFERENCES
         Name of Company                                            Address                           Yes        No




      Name of Person                      Title & Phone No.




      Date :                              Rank :                 Signature of candidate:


 19
                                                   (FOR OFFICE USE ONLY)
      Form received by and on                                                        Acknowledged : Yes     No

      INITIAL INTERVIEW                   (Tick as applicable)

a)    Original licence Sighted ?
b)    STCW and Training Certificates sighted
c)    Documents verified for authenticity ?
d)    Experience confirmed by interview
                                          Grade
      Professional Knowledge                                     Officer like qualities
      Adequate Experience in Rank                                Track record
      Suitability for promotion                                  References taken ?
      Personality & Attire                                       Reasons for short tenures
      Attitude                                                   Reasons for frequent changes
      Safety & Pollution Prevention                              ISM & ISPS awareness
      Fluency in English                                         Long Term Prospects

      Grade :- VG - Very Good         G - Good       S - Satisfactory     P - Poor
      CM's Assessment : (1st stage )
                 ACCEPT      / REJECT     Signature of C.M.
      G. M's assessment : (2nd stage)
                 ACCEPT      / REJECT     Signature of C.M.

      APPROVAL STATUS                     ACCEPT                 REJECT

      Approved By Head Office                              Yes                     No              N/A



      CMS ENTRY                                                  DATE : ____________________

      PD TO Head Office / Principals                             DATE : ____________________

      FLAG STATE DOCUMENTS APPLIED                               DATE : ____________________

      ID NO : __________________

				
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