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