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- 1. APPLICATION FORM FOR CREW PostApplied ELECTRICAL OFFICER N.I.C.No.562930760X Names as per Passport Surname First Othernames Other names FERNANDO VIRGEN ROMEO SUSIL KUMAR Date of Birth Place of Birth Nationality Contact Number Email 19-10-1956 NEGOMBO SRILANKAN +94789385467 +94112449509 virgelsusil@yahoo.com Permanent Address 165 NEW CHETTY STREET, COLOMBO-13, SRI LANKA Details Number Date of Issue Expiry date Place of Issue Passport N5289447 22-09-2014 22-09-2024 COLOMBO CDC C 012159 29- 01- 2015 29-01-2019 COLOMBO NOK Details Name Mrs. MEGALA FERNANDO Relationship SISTER Contact No.2449509 Address 165 NEW CHETTY STREET, COLOMBO – 13, SRILANKA EDUCATIONALQUALIFICATIONS G. C. E. (O/L) Grade 10 (Science Subjicts) SAILINGEXPERIENCE(STARTINGWITH MOST RECENT) Company Vessel Name Vessel Type GRT Rank Period From To UAE WESTERN SHIPPING MV TERNGOSEA SUPPLY VESSEL 2557 ELECTRICIAN 20-04-2013 5-06-2014 FAL SHIPPING SEA SPIRIT OIL TANKER 22838 E/OFFICER 6-03-2012 18-02-2013 DAMMAM SHIPPINGCO MV SAFANYIV SUPPLY VESSEL 773 ELECTRICIAN 30-11-2011 17-01-2012 FAL SHIPPING CO.,SHARJAH AL KHAN OIL TANKER 6691 E/OFFICER 04-04-11 16-11-11 DO ZABEEL OIL TANKER 6402 E/OFFICER 19-05-10 20-08-10 DO WASET OIL TANKER 8226 E/OFFICER 03-02-10 15-05-10 DO WASET OIL TANKER 8226 E/OFFICER 11-10-08 06-05-09 DO SEA SPIRIT OIL TANKER 22838 E/OFFICER 31-10-07 19-05-08 DO GULF SUCCESS OIL TANKER 34174 E/OFFICER 06-04-06 18-09-07 NAVISTAR SHIPPING M/V ARKAS BULK CARRIER 64828 ELECTRICIAN 14-05-98 21-02-99
- 2. STCW COURSES ATTENDED AND CERTIFICATES HELD Course/Certificate Certificate No Date of issue Valid till Place of issue Fire Fighting RTST504061735 31-01-15 30-01-20 GALLE-SRI LANKA Elementary First Aid LATS-EFA- 20355 11-02-15 10-02-20 PANADURA- SRI LANKA Personnel Survival Techniques LATS-PST- 15459 5-02-15 4-02-20 PANADURA- SRI LANKA Personnel Safety and social Responsibilities SD331/05- 3410634 14-12-05 VALID MALABE-SRI LANKA Watch Keeping Certificates M.S.0769 27-09-89 VALID COLOMBO- ISPS SD-338/06- 03/0080 1-03-2006 VALID MALABE-SRI LANKA PSCRB Oil Tanker Familiarization SD-320/08- 11/0163 23-06-08 VALID MALABE-SRI LANKA Chemical Tanker Familiarization SD-320/08- 11/0163 23-06-08 VALID MALABE-SRI LANKA Proficiency in English Maritime LC- 0817/024/0002 2-02-15 VALID MALABE-SRI LANKA Endorsement – Oil Tanker Deck Rating / Motorman- MEO Ed- 275/016/0023 27-2-06 VALID Marine Technology and Electronic Diploma 1225 7-01-76 NUGEGODA- SRI LANKA MEDICAL CERTIFICATE MEDICHECK- COLOMBO 12-09-14 2016 COLOMBO-04 Yellow Fever 4-09-07 09-2008 SHARJAH Drug 10-03-11 09-03-16 MUMBAI Alcohol I do herebydeclare that all informations above are correct to the bestof my knowledge. …V.R.S.K.FERNANDO…………………………………………………. Name & Signature