APPLICATION FORM

1 Position Position applied for: Are you willing to accept any other positions? If YES, which positions would you consider? Personal details YES NO DECK CADET YES

Name: (Last Name) HASNAT (First Names) SARKER MOHIUDDIN Date/place of birth: 16/10/1989 COMILLA Nationality: BANGLADESHI Permanent address: VILL: SAAJGHAR POST: MONDHAVAG BAZAR P.S: B.PARA DIST: COMILLA Height in cms Mailing address: 170 CM Weight in Kgs 58 KG Boiler suit/ safety shoe size Post code: 3500 +8801717077666 No.: C/O: ABDUL KHALEQUE HOUSE :14 ROAD: 15 NIKUNJA-2 ,DHAKA Post code: 3 Education Background School / College JHENIDAH CADET COLLEGE,JHENIDAH JHENIDAH CADET COLLEGE,JHENIDAH BANGLADESH MARINE ACADEMY,CHITTAGONG Identity documents From 2001 2005 2008 To 2005 2007 2009 Highest Qualification Attained G.P.A : 5.00(OUT OF 5.00) G.P.A :5.00(OUT OF 5.00) FIRST CLASS PLACE OF ISSUE COMILLA
CHITTAGONG

MEDIUM/ 8

1229

No.:

+8801711505961

DOCUMENT COUNTRY NUMBER DATE OF ISSUE Passport: BANGLADESH E 0910762 30/12/2009 Seaman book: BANGLADESH C/O/5857 07/01/2010 Any other visa SINGAPORE Do you hold a US Visa C1? YES/NO NO Do you hold a US Visa D? YES/NO NO Have you been rejected for any visa applied for? YES/NO NO If YES, please state the country and reasons 5 Family details

DATE OF EXPIRY 29/12/2014 06/01/2015

NEXT OF KIN Relationship: BROTHER IN -LAW Name: (Last Name) HASAN (First Names) MOHAMMAD C/O: ABDUL KHALEQUE HOUSE :14 ROAD: 15 NIKUNJA-2 ,DHAKA Address: Contact telephone numbers:
1st. +8801711505961 Post code: 2nd. 1229

Courses attended and certificates obtained Model 1.01 1.02 1.07 1.08 1.09 1.14 1.15 1.19 1.20 1.21 1.23 2.03 Course Tanker Familiarization Adv.Tank.(OIL) Adv. Chemical Tanker Safety Radar Observer ARPA Radar Simulator Medical & First Aid Ship Security Officer Personal Survival Technique Basic Fire Fighting Human Relationship-PSSR Proficiency In Survival Craft Advance Fire Fighting GMDSS STCW Endorsement
Institution

Place
DHAKA

IIMT

Date of Issue 29/12/2009

Cert. No. TF/0952/01

Valid Until 28/12/20144

BANGLAD ESH

CHITTAGO NG CHITTAGO NG CHITTAG

16/11/2009 24/03/2009 21/10/2009 26/03/2009

946 2225 962 934

15/11/2014 23/03/2014 20/10/2014 25/03/2014

BANGLA DESH BANGLA DESH BANGLA DESH

ONG CHITTAGO NG

References (Please give the name and address of your current or immediate past employer) Name of company Name of person to contact Address No.

8 Automatic review If immediate employment is not available do you wish to be considered for future vacancies? If YES, please give any alternative contact details not shown in Section 2 9 Declaration I hereby declare that the above particulars are true and authorize you to contact the referees listed above. YES/NO YES

SARKER MOHIUDDIN HASNAT Signature

Date:

21/02/2010

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