ASM ALLIANCE MANAGEMENT SERVICES ( India ) P.

LTD
Office # 305, ACME Plaza, Opp Big Cinema, Andheri
Kurla Road, JB Nagar, Andheri East, Mumbai 400 059.
License No. RPSL-MUM-405 Valid till 31.10.2021

APPLICATION FORM (Engine Dept)

1 Position Candidate
Position applied for: Engine Fitter
Are you willing to accept any other positions?
If YES, which positions would you consider?
Readiness From From Tomorrow

2 Personal Details
Tiwari Ram Pratap
Last Name: First Name: Middle Name:

Date of birth 01.10.1980 Place of birth Deoria Uttar Pradesh

Height 170 cm Weight 80 ID Mark Blood Group B positive

Boiler
Chest 45 cm Waist 36 XXL Safety Shoe 10 Cap
Suite
National ID Indian Passport Nationality Indian Company ID
Address: Village - Makunhi,Post - Noonkhar, Police station - Khukhundoo, District - Deoria, Uttar Pradesh

Postal code: 274501 Hand Phone No. 9839616106 SKYPE ID

Telephone No. 8957133139 E-Mail ID: ramprataptiwari01@gmail.com

3 Education Background
Highest Qualification
Name From Year To Year
Attained
Bihar school examination board Patna 1995 1995 Second Division
School

College Bihar intermediate education council 2002 2002 Second Division

Pre Sea Training

Other Industrial training institute 2003 2005 Second Division

Qualifications

4 Identity Documents

DOCUMENT COUNTRY NUMBER ISSUE DATE PLACE EXPIRY DATE

Passport: India P2660760 21.07.2016 Lucknow 20.07.2026

Note: Please follow DD/MM/YY for date format wherever applicable 1|Page
Issue 01 Rev 01
 ASM ALLIANCE MANAGEMENT SERVICES ( India ) P. LTD
Office # 305, ACME Plaza, Opp Big Cinema, Andheri
Kurla Road, JB Nagar, Andheri East, Mumbai 400 059.
License No. RPSL-MUM-405 Valid till 31.10.2021
Seaman’s book: National MUM 261826 08.07.2016 Mumbai 07.07.2026
Bahamian
Liberian
Panamanian
Other -Norway
Seaman ID Card YES / NO
Visa – US ‘C1/D’ YES / NO
Other Visa YES / NO
Yellow Fever Vaccination YES / NO 02686 08.11.2016 Mumbai 07.11.2026
Holding Australian MCV YES / NO

5 Family Details

Next Of Kin / Nominee Marital Status : Relationship : Wife Marriage Date : 05.03.2002
Last Name: Tiwari First Name: Neelam
Address: Village - Makunhi,post-Noonkhar, district-Deoria
Postal code: 274501
 Hand Phone No. Telephone 9839616106
Relation Name P.O.B. D.O.B. No.
PPT NO. D.O.I. P.O.I. D.O.E.

Note: Second Next Of Kin / Nominee (In case of voyage with family)
Relation Father Name C B Tripathi

Address: Village-Makunhi,Post-Nookhar, District-Deoria

Mother’s Name
 Hand Phone No. 9839616106 Telephone No. 8840667780

6 National Certificate of Competency (Highest certificate of competency held)

Class/Grade Issuing Country Certificate No. Date Issued Place Issued Valid Until
COC

6a National Dangerous Cargo Endorsements

Endorsement
Certificate No. Date Issued Place Issued Valid Until
Type
Petroleum
Liquefied Gas
Chemicals

7 Flag State Equivalent Certificates Of Competency issued by other countries (Issued by countries other than in
Section 6)
Class Issuing Country Certificate No. Date Issued Place Issued Valid Until
Liberia
Panama
Bahamas

7a Flag State Equivalent Dangerous Cargo Endorsements (Issued by countries other than in Section 6a)

Endorse Type/
Country Certificate No. Date Issued Place Issued Valid Until
Level
Liberia
Marshall Islands

Note: Please follow DD/MM/YY for date format wherever applicable 2|Page
Issue 01 Rev 01
 ASM ALLIANCE MANAGEMENT SERVICES ( India ) P. LTD
Office # 305, ACME Plaza, Opp Big Cinema, Andheri
Kurla Road, JB Nagar, Andheri East, Mumbai 400 059.
License No. RPSL-MUM-405 Valid till 31.10.2021
Panama

8 Certificates ( STCW and Value added)

Course Institution Place Issue Date Cert. No. Expiry Date
Personal Survival Techniques l Institute of Marine Lucknow 17.06.2022 1050146112210192 26.12.2022
education and 1
Fire Fighting – Basic ( FPFF) Institute of Marine Lucknow 17.06.2021 1050146122210142 16.12.2022
/ Advanced education and 2
Elementary / Medical First Aid / research lucknow
Shipping Mumbai 24.06.2017 16103005631111 23-12-2022
Medical Care corporation of India
Proficiency In Survival Craft & RB Asha international Mumbai 08.10.2017 AIIMT/MUM/ 07.10.2022
Human Relations – PSSR institute
BP marrin Mumbai 09.06.2016 PSCRB/
BPMA/PSSR/ 08.06.2022
Security Training for Seafarers on Academy
Ramana Academy Mumbai 14.07.2015 3263/2016
Ram/ssds2548 Lifetime
Designated duties maritime
Ship Security Officer
Ship Security Awareness
Tanker Familiarization (Oil)
Tanker Familiarization (Chem)
Tanker Familiarization (LPG)
Advanced Oil Tanker Course
Advanced Chemical Tanker
Course
Advanced LPG Tanker Course
Engine Team management
Bridge & Eng. Room Resource
Mgmt
Ship Safety Officers
Marine Environment Protection
ISPS Code Familiarization
Risk Assessment & Accident
Investigation
Hazmat
Watch Keeping for Ratings
Engine Room Simulator
Electro Technical Officer Cert.
Planned Maintenance System
AMOS etc

Note: Please follow DD/MM/YY for date format wherever applicable 3|Page
Issue 01 Rev 01
 ASM ALLIANCE MANAGEMENT SERVICES ( India ) P. LTD
Office # 305, ACME Plaza, Opp Big Cinema, Andheri
Kurla Road, JB Nagar, Andheri East, Mumbai 400 059.
License No. RPSL-MUM-405 Valid till 31.10.2021

Note: Please follow DD/MM/YY for date format wherever applicable 4|Page
Issue 01 Rev 01
 9 Record of Previous Service
9
*NOTE: Sea service must start with last vessel served details and run up to his beginning of sea service

VESSEL MAIN ENGINE SIGN ON SIGN OFF

YEAR OF DURATION
VESSEL NAME COMPANY TYPE FLAG G.R.T. D.W.T. B.H.P. RANK DATE DATE
BUILT Maker Type DD/MM/YY DD/MM/YY
MM-DD

Malviya 33 Great offshore Supply Indian 6278 Fitter 14.09.2010 17.12.2010 3 months,3
day

Malviya 33 Great offshore Supply Indian 6278 Fitter 18.12.2010 03.01.2011 16 days

Malviya 33 Great offshore Supply Indian 6278 30.04.2011 04.05.2011 6days

Fitter
Malviya 33 Great offshore Supply Indian 6278 Fitter 05.05.2011 08.06.2011 33 days

Malviya 33 Great offshore Supply Indian 6278 Fitter 25.11.2011 15.01.2011 50 days

Malviya 33 Great offshore Supply Indian 6278 Fitter 01.12.2012 08.01.2013 38 days

Malviya 33 Great offshore Supply Indian 6278 Fitter 24.01.2013 02.04.2013 69 days

Malviya 33 Great offshore Supply Indian 6278 Fitter 03.04.2013 09.04.2013 5 days

Malviya 33 Great offshore Supply Indian 6278 Fitter 09.12.2013 23.01.2014 45 days

Ocean sapphire Samson Marine Supply Indian 2921 Fitter 18.02.2017 14.06.20 132 days

Post Constant Posh marine Supply Singapore 2736 Fitter 10.11.2017 04.12.2017 25 days

MB TCI PRABHU TCI Seaways Contenor Indian 2545 Fitter 15.04.2018 02.05.2018 17 days

MB LTS 3000 V Ship Dp 1 Indian 30628 Fitter 07.08.2018 12.10.2018 63 days

MB CSCL SYDNEY Sea Tech Contenor Span 39941 FITTE 22.10.2018 08.11.2018 17 days
R
DSB SEAMAC 1 SEAMAC Ltd Diving Indian 2685 Fitter 28.10.2019 11.01.2020 74 days
support vissel
Seaways 16 Seaways international Supply Singapore 1566 Fitter 16.03.2020 22.06.2020 97days

Note: Please follow DD/MM/YY for date format wherever applicable 5|Page
Issue 01 Rev 01
 9 Record of Previous Service (Continue)
9
*NOTE: Sea service must start with last vessel served details and run up to his beginning of sea service

VESSEL MAIN ENGINE SIGN ON SIGN OFF

YEAR OF DURATION
VESSEL NAME COMPANY TYPE FLAG G.R.T. D.W.T. B.H.P. RANK DATE DATE
BUILT Maker Type MM-DD
DD/MM/YY DD/MM/YY

DSB SEAMAC 1 SEAMAC Ltd Diving Indian 2685 Fitter 02.02.2021 12.04.2021 63 days
support vissel

Note: Please follow DD/MM/YY for date format wherever applicable 6|Page
Issue 01 Rev 01
10 For Engineers (Please provide Makers, Model & Capacity details)

Auxiliary Engines

Generators

Cranes / Grabs

Purifiers and Boilers

11 Sailing Experience: (Please advise PRESENT RANK EXPERIENCE on each type of vessel)

CONT/RFG G. CARGO BC/OBO/RR PCC/PCTC OIL/VLCC CHEMICA PRODUCT LPG/LNG OTHERS TOTAL RANK
(MM-DD) (MM-DD) (MM-DD) (MM-DD) (MM-DD) L (MM- (MM-DD) (MM-DD) (MM-DD) EXPERIENCE
DD)

LAST SALARY DRAWN EXPECTED SALARY

12 References (Please give the name and address of your current or immediate past employer)
Name of Company
Name of person to contact
Address

 No. / Facsimile
E-Mail / Website

13 Miscellaneous (Please give the details of your FC account)

Name of Bank Punjab National Bank Branch Noonkhar
Account Name Rampratap Tiwari
Address Village-makunhi, post-Noonkhar district-Deoria,pin- 274501

Account No. 1792000100219440 Swift / BIC Code (PNB)

14 Medical history
Have you ever signed off a ship due to medical reasons? Yes / No
Have you undergone any operation in the past? Yes / No
Have you consulted a doctor during the last 12 months for an illness/accident? Yes / No
Do you have any health or disability problems now? Yes / No

(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)

15 Declaration
I hereby declare that the above particulars are true and authorize you to contact the referees listed above.
15.01.2022

R.p.Tiwari
Name/Signature Date

Note: Please follow DD/MM/YY for date format wherever applicable 7|Page
Issue 01 Rev 01