Brukaan Officers Application Form

Application form for Officers
PHOTO
508,Mayuresh Cosmos, Tel : +91 22 27563580

Sector-11,CBD Belapur,, Fax : +91 22 27563581
Navi Mumbai-400614, Maharashtra, India. E mail: hr@brukaanship.com
Brukaan ID NO:
Position Applied for :
Are you willing to accept a lower rank? YES / NO
Date of Availability:
PERSONAL DETAILS
1. GENERAL
Name: (Last Name) (First Name)
Date of Birth: Place of Birth: Nationality:
Permanent address:
Post code:  No.:

E-Mail address: No.:
Present address:
Post code:  No.:

Civil Status : Single / Married / Separated / Divorced / Widowed.
Height : Cm: Weight : Kg: BMI:
Boiler Suit Size : Shoe Size : Food: Veg. / Non Veg.
Nearest Airport (Domestic / International) :
2. FAMILY DETAILS.
Full Name of Next of Kin : Relationship :
Address of Next of Kin :
Post code:
Contact telephone numbers:  No.: No.:
Family Date of
Name Anniversary
D.O.B PPT. No. D.O.I P.O.I D.O.E ECNR
Data
Wife
Child (M/F)
Child (M/F)
Child (M/F)
FPD 01 Rev No 2 Date: 01-Aug-2013 Page 1 of 5

3. MEDICAL HISTORY
(a).Have you ever signed off from a ship due to Medical reasons,(If Yes give details) Yes / No
Name of the Vessel : Date of Occurrence :
Brief description of Illness / Injury / Accident :
(b). Did you suffer or Are you Presently suffering from any disease likely to render you unfit
Yes / No
for service at sea or likely to endanger the Health of others on board.
(c). Are you addicted to alcohol or drugs of any kind? Yes / No
(d).Have You suffered from Following?
Malaria Diabetes Epilepsy Nervous Disability Hepatitis of any kind
Yes / No Yes / No Yes / No Yes / No Yes / No
(e) Did You ever undergo psychiatric treatment? Yes / No
TRAVEL DOCUMENTS & VISA

Passport No: Date of Issue Place of Issue Date of Expiry ECNR Blank Pages
MUI Membership No. D.O.E.

U.S.VISA
Any Other VISA
ACADEMICS & PROFESSIONAL QUALIFICATIONS

1. EDUCATIONAL BACKGROUND.
School / College From To Highest Qualification attained.
2. PRE SEA TRAINING / APPRENTICE SHIP.

Name of Institute / College From To Grade / Marks Type of Degree
CERTIFICATIONS & COURSES

1. CDC DETAILS.
Date of Expiry
Seaman’s Book Number Date of Issue Place of Issue
Indian
Liberian
Panamanian
Marshall Islands
Bahamas
Vanuatu
IOM
Bermuda / Maltese
Others
2. INDOS DETAILS.
INDOS Number
3. LICENSES.

Date of
License Grade Number Date of Issue Place of Issue
Expiry
Indian
U.K.
Singapore
Australian
Liberian
Panamanian
Vanuatu
IOM
Bermuda
Others
4. DETAILS OF COURSES & CERTIFICATES.
Date of
Course Type Number Date of Expiry Issued By
Issue
Advanced / Basic Fire Fighting
Proficiency in Survival Craft / Rescue Boat / PST
Elementary / Medical First Aid / Medicare
Personal Survival & Social Responsibility (PSSR)
Radar Observer / ARPA
Radar Simulator (RANSCO) / ENS
Ship Handling Simulator
LCHS
GMDSS / MCC
Petroleum Tanker Safety (STPOTO)
Chemical Tanker Safety (CHEMCO)
Gas Tanker Safety (GASCO)
Oil Tanker Familiarisation (OTFC)
Chemical Tanker Familiarisation (CTFC)
Gas Familiarisation (GTFC)
Ship Simulator
Engine Room Simulator
ECDIS ( Generic - IMO – 5 days)
ECDIS ( Type Specific) – Pls specify Make -
Bridge Team Management
Bridge / Engine Resource Management
Revalidation Course
Security Training for Seafarers DSD
Yellow Fever
ISPS / SSO / CSO
Others – GMDSS Endorsement
5. DANGEROUS CARGO ENDORSEMENTS
Grade / Level Place of
Types Number Date of Issue D.O.E
I / II Issue
Oil
Chemical
Liquified Gas

PREVIOUS SEA SERVICE
( Date commencing from last vessel )
Name of DWT
Built Engine UMS Total Reason for
S.No. Owners / Name of Vessel Type Or BHP Rank From To
Year Type Y/N MM/DD S/Off
Manager GRT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Last Wages Drawn :___________________ Expected Salary : _______________________

MISCELLANEOUS
1. DECK OFFICERS.
Bulk: Type of cargo carried
Product: Type of cargo carried
Chemical: Type of cargo carried
Tanker: Type of pumps
2. ENGINEERS.
Automation. (Type)
Cranes. (Type)
Grabs. (Type)
3. ELECTRICAL OFFICERS.
Automation. (Type)
NOR Control System. (Type)
Cranes Hydraulics, Electro Hydraulics. (Type)
PLC. (Type)
4. GENERAL TRADING AREA OF VESSELS
5. OIL MAJOR INSPECTIONS.

CDI Yes / No
Port State Control. (Please Specify)
Others. (Please Specify)
6. DRY DOCKING EXPERIENCE.
DECLARATION
I hereby affirm that all this information provided by me in this application is true and correct to the best of my knowledge
and belief; further, that no Certificate of competency or License issued to me has ever been Revoked or suspended. I also
certify that my medical history contained above is True and any false statement or undisclosed material information about
past illness or injury will disqualify me from any employment benefits and claims.
Date _______________ Rank ________ Signature of Seaman _-______________________

This Is Computer Generated CV, Doesn’t Require Signature

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Application form for Officers

508,Mayuresh Cosmos, Tel : +91 22 27563580

Post code:  No.:

Post code:  No.:

FPD 01 Rev No 2 Date: 01-Aug-2013 Page 1 of 5

Brief description of Illness / Injury / Accident :

TRAVEL DOCUMENTS & VISA

MUI Membership No. D.O.E.

Any Other VISA

ACADEMICS & PROFESSIONAL QUALIFICATIONS

2. PRE SEA TRAINING / APPRENTICE SHIP.

CERTIFICATIONS & COURSES

FPD 01 Rev No 2 Date: 01-Aug-2013 Page 2 of 5

FPD 01 Rev No 2 Date: 01-Aug-2013 Page 3 of 5

Last Wages Drawn :___________________ Expected Salary : _______________________

FPD 01 Rev No 2 Date: 01-Aug-2013 Page 4 of 5

Bulk: Type of cargo carried

Product: Type of cargo carried

Chemical: Type of cargo carried

Tanker: Type of pumps

5. OIL MAJOR INSPECTIONS.

Date _______________ Rank ________ Signature of Seaman _-______________________

FPD 01 Rev No 2 Date: 01-Aug-2013 Page 5 of 5

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Last Wages Drawn :_ Expected Salary : _____

Date _______ Rank Signature of Seaman _-______________________