COURSE ENTRY FORM (DG Approved Course)

ANGLO-EASTERN MARITIME TRAINING CENTRE
 

PERSONAL PARTICULARS

FULL NAME : (as per your certificate)
SurName: GivenName(S):
PLEASE MENTION YOUR NAME AS YOU WANT IT TO APPEAR ON YOUR CERTIFICATE
Date of Birth Place Of Birth Nationality

PERMANENT ADDRESS
Permanent Address
Pin Code Telephone Number Mobile No.
Email Address

ADDRESS IN DELHI/ MUMBAI
Address in Delhi/Mumbai
Pin Code Telephone Number

DISCHARGE BOOK NUMBER
Discharge Book No.: Place of Issue Date of Issue

PASSPORT NUMBER
Passport No. Place of Issue Date of Issue

LOCATION DETAILS
Country* State* City*
RECEIPT NO.(OFFICE USE ONLY)

PRE SEA MARITIME
Pre-Sea Maritime Training

(Name Of Institution)
Pre-Sea Maritime Place Type of Pre-Sea Course
Year Of Passing Out DGS Approved Yes  No
Current Rank Held

PROFESSIONAL PARTICULARS :

SEA SERVICE
NAME OF SHIP (last five) Y M Days Rank
TOTAL SEA SERVICE

PRESENT COMPANY DETAILS

Present Company Reference Person Tel No.
Mobile No. (Specify the code if any)
DC Endorsement  PET  CHEM  GAS
No.
Issue Date
Issue Place

PLEASE TICK (✔) AND SUBMIT COPIES OF YOUR PERSONAL DOCUMENTS AS MENTIONED BELOW.

PASSPORT
INDOS
PHOTOGRAPH
CONTINUOUS DISCHARGE CERTIFICATE

"ADDITIONAL CERTIFICATE COPIES TO BE UPLOADED / SUBMITTED FOR THIS COURSE". Kindly tick (✔) and upload the documents on your profile page to complete your course entry form.

CERTIFICATE OF COMPETENCY DETAILS - (Kindly fill your CoC details as per your Grade.)
COC Number COC Grade
Place of Issue Date of Issue

COURSE EXPECTATION:
(Kindly mention the purpose of your attending this course, what your expectations are from the course and the topics that you would like covered)

DECLARATION :

I hereby declare, to the best of my knowledge, that the information given above is true. On admission, I undertake to attend all classes regularly and punctually and to comply with all rules and regulations of the Training Centre. I have not been Restricted / Prohibited / Debarred from attending any course or from appearing in any examination by D.G. Shipping / MMD / any other authority. I agree that fees once paid shall be non refundable and non-transferrable.
DATE SIGNATURE OF CANDIDATE
VERIFIED BY MTI
Date :
Checked By :
Remarks :
Form No. CO/10 A – Quality Manual A E M T C