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1. Personal Data
First Name KAUSHIK Middle Name (s) Last Name / Surname BASU
AFFIX YOUR RECENT PASSPORT SIZE PHOTOGRAPH HERE (Attach separately if filing electronically)
Date of Birth: 19 / 11 / 75
(DD / MM / YY)
Religion: Gender : Male HINDU Female 1 Select from : Single Married Divorced Common Law Partner Widowed Separated Rank applied for: Chief Officer Primary / Permanent Address: Anandamoyee Appertment 8/15 Nilkantha Chatterjee Street; Belghoria. City: Kolkata State: West Bengal Nearest Airport : Dum Dum Mobile Tel. 9830259210 Contact Method : Collar:
cm
Until: __ / __ / _
SAME AS PERMANENT ADDRESS City: State: Phone: Email: Mobile Phone Home Phone Cap: cm Shoe Size: Post Post Code: Country: Post Code: 700056 Country : India Home Tel: 913325442776 Fax: Fax
Email Chest: cm
Waist: cm
Inside Leg: cm
2.
Seamans Book (National) Passport US Visa C1/D National Seaman ID Yellow fever Australia MCV
03 / 03 / 00 28 / 03 / 07 04 / 04 / 08 / / 24 / 05 / 02 / / / / / /
18 / 05 / 15 27 / 03 / 17 02 / 04 / 13 / / 23 / 05 / 12 / / / / / /
Social Security
Number: Issuing Country Number: AHMPB8510D
Personal Tax
Issuing Country: INDIA
Chapter 14 CRW13 Application Form File Ref: Office File: 11B Revision Number: 02
Relationship1
Gender : Male
Select From : Spouse Partner Child Parent Grand Parent Other Relative (Please Specify)
Family Data:
Relationship Spouse Child Child Child Child Child
2
First Name
2
Last Name
Date of Birth
Passport No.
Issued
Place
Valid Until
/ Partner M M M M M F F F F F
PAYEL ISHAN
3
BASU BASU
USA
28 / 01 / 81 18 / 11 / 07 / / / / / / / /
Canada
H1202879 G8207402
INDIA INDIA
UK
KOLKATA KOLKATA
03 / 11 / 18 25 / 05 / 13 / / / / / / / /
Brazil
Schengen
Other
4. STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications: (Add separate sheet if data exceeds space available.) Country of Issue Number Description of Cert / Course (A) Reg I Personal Training Record Reg I/14 Medical Fitness Cert Reg I/9 Date of Issue (DD-MMYY) Date of Expiry (DD-MMYY) Place of Issue Issuing Authority / Body
/ / / / 29 / 01 / 00 09 / 02 / 00 11 / 12 / 97 05 / 02 / 00 17 / 05 / 02 / / 08 / 06 / 01 15 / 03 / 01 30 / 11 / 06
/ / / / / / / / / / / / / / / / / / / / / /
(B) Reg VI / 1 Basic Safety Training INDIA SMC/PST/569 Personal Survival Techniques Elementary First Aid Fire Fighting & Fire Prevention Personal Safety & Social
Resp. (C) Reg VI / 2 4 Additional Training Proficiency in Survival Craft & Rescue INDIA 01779 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)
MASTER (F.G)
4
INDIA
IFOO10312
03 / 05 / 10 / / / / / / / / / /
05 / 04 / 15 / / / / / / / / / /
KOLKATA
GOVT.0F INDIA
Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you Other mandatory/recommended Certificates / Courses (as applicable) INDIA L/26/07 ARPA (Reg II/1 + Solas) 26 / 04 / 02 / / INDIA K/20/03 Radar Simulator 21 / 04 / 02 / / English Language Bridge Team / Resource Mgmnt Hazmat (US 49CFR)
(E)
INDIA
Q/32/01
/ / 21 / 04 / 05 / /
/ / / / / /
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.
Chapter 14 CRW13 Application Form File Ref: Office File: 11B Revision Number: 02
19 / 02 / 10 13 / 04 / 05 17 / 04 / 08 / / / /
Date of Issue (DD-MMYY)
/ / / / / / / / / /
Date of Expiry (DD-MMYY)
Country of Issue
Number
Place of Issue
(F)
GMDSS Certificates (including flag state endorsements) GMDSS (Main Issuing INDIA GOC9071 07 / 02 / 02 Authority) INDIA GOC/MMD/KOL/03643 09 / 04 / 07 GMDSS (Flag State) GMDSS (Flag State) / / GMDSS (Flag State) GMDSS (Flag State) GMDSS (Flag State)
/ / / / / /
06 / 02 / 12 06 / 02 / 12 / / / / / / / /
(G)
Reg V / 1 Special Requirement for Tankers Country Level1:Asst Description Number Level2:Incharge of Issue Endorsement Oil Endorsement Chem I/II Endorsement Chem III Endorsement Gas Tanker Familiarisation 1 Tanker Familiarisation 1 Tanker Familiarisation
LEVEL 2
Para Para 1 (Chemical) Para
(Oil) (Gas)
Special Tanker Safety (Oil) Para 2 Special Tanker Safety (Chemical) Para 2 Special Tanker Safety (Gas) Para 2
INDIA INDIA
DC/D/KOL/0509 6 41/1744/00237
09 / 05 / 08 / / / / / / / / / / / / 25 / 07 / 02 / / / /
08 / 05 / 13 / / / / / / / / / / / / / / / / / /
Place of Issue
KOLKATA KOLKATA
DGS INDIA
(H) V/2 and V/3 Special requirement for Passenger / Ro-Ro Passenger Vessels Vsl Type Date of Country of Place of Number -Pax / Issue Issue Issue RoRoPax (DD-MM Crowd Management Description Crisis Mgmnt & Human Behaviour Pax Safety, Cargo Safety & Hull Integrity Pax Safety Familiarisation Training Safety Training
RoPax
/ / / / / / / / / / / /
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
INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP INDIA STEAMSHIP
(1)
INDIAN/RATNA PUJA INDIAN/RATNA URVI INDIAN/RATNA URVI INDIAN/RATNA PUJA INDIAN/RATNA URVI INDIAN/RATNA URVI INDIAN/RATNA SHALINI
17 / 11 / 09 28 / 04 / 09 06 / 11 / 08 26 / 10 / 07 13 / 08 / 07 26 / 01 / 06 16 / 12 / 04 / / / / / / / / / /
Chapter 14 CRW13 Application Form File Ref: Office File: 11B Revision Number: 02
Bulk Carrier Cellular Chem Carrier Chem Carrier Dredgers Dynamic Fishing Vsl FloatingStorage
FloatgProdStor General Cargo Heavy Lift Vsl Lash Live Stock LNG Carrier Log/Timber LPG Carrier
ML MS NV RIG OS OB O/ OT
Multi-purpose MultiServiceVes Naval Ship OffShore Oil Rig OffShore Supply Ore/Bulk/OilCarr Ore/OilCarrier Other
PA RF R/R PR SA SR SU TU
Chapter 14 CRW13 Application Form File Ref: Office File: 11B Revision Number: 02
/ /
(B) Have you undergone any operation in the past? If yes, please provide following details:
Details of operation Date
Yes
No
Present condition
Period of disability
Details of illness / accident
/ / / / / /
Date
Therapy/Treatment
(C) For what illnesses or accidents have you consulted a doctor during the last 12 months? N/A
Details:
/ / / / / /
7.
Bank Details:
GARIAHAT;; KOLKATA; INDIA Account Name SAVINGS ACCOUNT Account No. 023 382237 006 Sort Code
8.
General
(A) Have you ever been denied a foreign visa? Yes No If yes, state which country and reason (if known) (B) Have you been the subject of a court of enquiry or involved in a maritime accident? If yes, please attach details (C) Give details below of two recent employers who we may contact for references:
Reference 1 Name of Company Name of person to contact Address
Yes
No
Reference 2
Country Telephone
INDIA STEAMSHIP MR. AMIT BASAK 44, PARK KOLKATA; INDIA. INDIA 9836310011
STREET;
I hereby declare that the above, including Medical History, is true. I further consent to the holding and processing by you and any of your direct or indirect parent or subsidiary or associated or affiliated companies (V Ships) and your or V Ships principals of personal data about me (including where appropriate data concerning racial or ethnic origin, religious beliefs, membership of a trade union, physical or mental health or condition, commission or alleged commission of an offence and the proceedings and the outcome of any proceedings relating thereto) for all purposes related to my application for employment on board vessels managed by V Ships or vessels owned or operated by third parties for whom V Ships is engaged to provide crew. I understand that this data will be stored in your databases in relation to my actual or potential employment by or through V Ships. Further, I confirm that the above may involve the transfer of my personal data within V Ships or to third parties worldwide.
Chapter 14 CRW13 Application Form File Ref: Office File: 11B Revision Number: 02
Chapter 14 CRW13 Application Form File Ref: Office File: 11B Revision Number: 02