UNISHIP MANAGEMENT PRIVATE LIMITED

305 - 306, Midas, Sahar Plaza Complex, Andheri - Kurla Road, Andheri (E), Mumbai-400059
Tel: + 91 22 66115000, Email : crewing@uniship.co.in
RPSL No. : RPSL-MUM-313 – DOE : 06.07.2019

Position applied for:

Surname:
Other name:
Father’s name: Photo
Date of birth:
Place of birth:
Date of Availability

Height [cm]: Shoes Size: Next of kin:

Weight [kg]: Overalls Size: No. of children <21 yrs:
Eyes Color: Hair Color:

Present address: Phone:

Mobile :
Permanent address: Email :
Skype Id :
1. NEXT OF KIN NAME, ADDRESS & CONTACT DETAILS
Present address: Phone:

Email :
2. PASSPORT DETAILS
Name (Country) No. Issued Valid Place of issue

3. VISA DETAILS
Country No. Issued Valid Place of issue

4. YELLOW FEVER INNOCULATION

Country No. Issued Valid Place of issue

5. SEAMAN BOOK (S)

Country No. Issued Valid Place of issue
INDIAN
Marshall Island
Liberian
Panama

6. EDUCATION AND TRAINING

Period Education institution, courses No. Degree

7. LICENSES OF COMPETENCE (endorsement)

License Endorsement
Country Capacity No. Issued Expires Level Issued Expired

WPIF/7.5/01 25 SEPTEMBER 2017 REV-2

 UNISHIP MANAGEMENT PRIVATE LIMITED
305 - 306, Midas, Sahar Plaza Complex, Andheri - Kurla Road, Andheri (E), Mumbai-400059
Tel: + 91 22 66115000, Email : crewing@uniship.co.in
RPSL No. : RPSL-MUM-313 – DOE : 06.07.2019
8. CERTIFICATES
Name No. Date of Date of Remarks
Issue expiry
Basic Safety Training [STCW 2010]
Proficiency in Survival Craft and Rescue Boats
Personal Survival Techniques
Fire Fighting – Advanced
Fire Prevention and Fire Fighting
Medical First Aid
Elementary First Aid
Shipmasters Medicare
Personal Safety and Social Responsibility
Radar Observation and Plotting [ROP]
Automatic Radar Plotting Aids [ARPA]
RANSCO/NARAS/NAEST
Oil Tanker Training – Advanced / Familiarization
Chemical Tanker Training – Advanced / Familiarization.
Gas Tanker Training – Advanced / Familiarisation
ISM Code course [ISM]
Bridge Team Management / Bridge Resource Management / Engine
Room Resource Management
Crisis Management and human behavior
Human Element and Leadership Management
Ship Security Officer Course
Security Training for Seafarers with Designated Security Duties.
Safety Officers Certificate
Risk Assessment and Management
Marine Accident and Incident Investigation
Ship Manoeuvring Simulator
Liquid Cargo Handling Simulator
ECDIS
ECDIS – Type specific
Dangerous Cargo Endorsement (OIL)
Dangerous Cargo Endorsement (CHEMICAL)
Dangerous Cargo Endorsement (GAS)
GMDSS
GMDSS Endorsement – for Indian GMDSS
Pumpman Course Certificate
Rating Watch-keeping Certificate II-4 / II-5 / III-4 / III-5
INDOS

9. PREVIOUS SEAGOING EXPERIENCE

Vessel’s Particulars Dates TOTAL
Crewing Company Rank Main Months
Name Type DWT/GRT BHP From To
Engine & Days
/
/
/
/
/
/
/
/
/

WPIF/7.5/01 25 SEPTEMBER 2017 REV-2

 UNISHIP MANAGEMENT PRIVATE LIMITED
305 - 306, Midas, Sahar Plaza Complex, Andheri - Kurla Road, Andheri (E), Mumbai-400059
Tel: + 91 22 66115000, Email : crewing@uniship.co.in
RPSL No. : RPSL-MUM-313 – DOE : 06.07.2019
BC Bulk Carrier CN Container Ship GEN General Cargo vessel
VCC Vehicles Carrier Ro-Ro Roll-On / Roll-Off VLCC Very Large Crude Carrier
Tkr-P Product Tanker Tkr-C Crude Tanker Tkr-Ch Chemical Tanker

10. TOTAL EXPERIENCE

FOR TANKERS FOR BULK
Years in Rank
Years on this type of vessel
Years on all type of vessel

11. PROFICIENCY IN LANGUAGES

Language Read Write Speak Tested by

12. MEDICAL HISTORY

Have you ever signed off a ship for medical reasons? YES / NO
Have you undergone any minor or major surgery in the past? YES / NO
Do you suffer from any health or disability problems now?

If the answer to any of the above is yes, kindly give details in brief on a separate page.

13. GENERAL
Have you ever been subjected to a court of enquiry or involved in a maritime accident? YES / NO
Have you ever had your professional licence suspended or revoked? YES / NO

If the answer to any of the above is yes, kindly give details in brief on a separate page.

14. DECLARATION
I hereby declare that the above particulars are true to the best of my knowledge.

Seafarer’s signature: Date:

15. SPACE FOR OFFICIAL USE

Assessment : Grade Application Status : Date :
Personality Forwarded
Attitude ACCEPTANCE DETAILS
Technical Knowledge ACCEPTED YES NO
English Knowledge REF.

Overall Assessment

Grade: A – Excellent, B – Good, C – Satisfactory, D – Average, E – Poor

Interviewed by _________________ Date : __________________

INTERVIEWER’S REMARK:

WPIF/7.5/01 25 SEPTEMBER 2017 REV-2