/ NORTHSTAR SHIP MANAGEMENT PVT. LTD.
Shop No. 4, Plot No.B-58, Ground Floor, RAVI KIRAN CO-OP. HSG. SCTY. LTD.
Near Monginis Cake Factory, Opp Tanishq Showroom, Off. Link Road, Andheri (W), Mumbai-400 053 Tel. No.- 022 26369357/ 26321331/ 26319312
Email- RPSL –MUM 314

BIO-DATA

Photo

SEAFARER ID: POST APPLIED FOR:

First Name:
Date of Birth: / Middle Name:
Place of Birth: / Last Name:
Nationality:
Present Address: / Permanent Address:
Email ID: / Contact No:
Languages Known: / Religion / Marital Status:
Next of Kin Information:
Name
Name / Relation:
Relation: / Contact No:
Contact No:
Boiler Suit Size: / Shoes Size:
Pre-Sea Training
Name of Institute / From / To / Type of Degree
Documents Held
Name / Number / Date of issue / Place of issue / Validity / Verified
Passport
CDC (Indian)
CDC (Liberian)
CDC (Panama)
CDC (Belize)
CDC (Others)
W.K (watch keeping)
COC
Indos No.
Medical Certificate
Name / Certificate / Date of Issue / Place of Issue / Validity
Yellow Fever
Medical
List of S.T.C.W 95/Other
Sr.No / Course Name / Certificate No / Date of Issue / Place of Issue / Academy Name
1. / FPFF
2. / PSSR
3. / PST
4. / EFA
5. / SDSD-SSO
Dangerous Goods Certificates
Sr.No. / Dangerous Goods Endorsements / Number / Date of issue / Place of issue / Validity
1. / Oil
2. / Chemical
3. / Liquified Gas
Sea Service Record (Beginning With Last Vessel Served)
Vessel Name / Vessel Type / GRT / BHP/Engine Details / Rank / Period / From / To / Company
Total Experience: / Year/s: / Month/s: / Day/s:
Reference:
A. / Merchant Navy/ Indian Navy:
(i) / Name: / Contact No: / Rank:
(ii) / Name: / Contact No: / Rank:
B. / Other:
(i) / Name: / Contact No: / Rank:
(ii) / Name: / Contact No: / Rank:

I HERE BY DECLARE THAT ALL THE INFORMATION PROVIDED IS TRUE AND I SHALL BE HELD RESPONSIBLE IF ANY OF THE INFORMATION PROVIDED IS FOUND INCORRECT.

Approved OR Rejected Records
NAME / DATE / REASON

APPLICATION (BIO DATA) Form No. NSM-F-03

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