FORM 29

(See Rule 72)

GOVERNMENT OF INDIA
MINISTRY OF SURFACE TRANSPORT
DIRECTORATE GENERAL OF SHIPPING
Application for Examination and Assessment for certificates under Merchant
Shipping (Standards of Training, Certification and Watch-keeping for Seafarers)

Application No. : SB/MMD(M)/2019/22231590 Received Date :20/09/2019

A. Grade of Examination : First Mate of a Foreign Going Ship

Place of Examination : MMD MUMBAI

1. Full Name : SURENDRA SINGH

(Block letters)

2. Permanent Address : 410206, New Panvel Maharashtra,

SB/MMD(M)/2019/22231590
3. Present Address : Villag Gangrani Post Horlapur Dist Kushinagaruttar Pradesh,Padrauna,275303 Uttar
Pradesh,India
4. Telephone Number : 9987518508
(with STD Code)
5. Nationality : INDIAN
(Proof to be produced)
6. Passport Number : Z7057526
7. Date and Place of Issue : 16/11/2022 At Mumbai
8. Continuous Discharge : MUM 117417
Certificate (C.D.C)
Number
9. Date and Place of Issue : 26/12/2003 At Mumbai
10. Date of Birth : 13/03/1969
(Proof to be produced)
11.Place of Birth : GANGRANI
12.Personal Identification : A CUT MARK ABOVE LEFT EYE
marks
13. INDos No : 05DL0591
14. Email Id : [email protected]
Note : Any Person who makes, causes to be made or assists in making any false representation for the purpose of obtaining for himself /

B. DETAILS OF SCHOLASTIC EDUCATION :

(Separate sheets must be attached)
1.Scholastic Education Level : Graduate (Bachelors Degree)
2.Principal Subjects : History, Sociology, Political Science
3. Year of Passing : 2003
4. School/College/ Board : Mumbai University Mumbai
5. Address of the Institution : Kalina mumbai

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C. DETAILS OF PRE-SEA TRAINING / MARINE ENGINEERING WORKSHOP :
(Separate sheet must be attached )

1. Training Institute
2. Address of the Institution

3. Attended From
4. Result
5. Courses Attended

D1. DETAILS OF SEA-GOING SERVICE (FOR DECK DEPARTMENT PERSONNEL) :

Port of Trade: Period

Gross
Name of Registry/ NCV/ FG/
Type Tonnage Rank From To Remarks
Ship Official Coastal
Number Months
Days

MT PADOSA Oil Tanker 6534 MONROVIA FG Second Officer 01/04/2021 17/10/2021 6 17

MT PADOSA Oil Tanker 6534 MONROVIA FG Second Officer 09/02/2020 13/10/2020 8 4

MT DAWN1 Oil Tanker 6253 PANAMA FG Second Officer 09/11/2018 25/05/2019 6 17

MT PADOSA Oil Tanker 6534 LIMASSOL FG Second Officer 28/08/2017 19/04/2018 7 23

IV
SB/MMD(M)/2019/22231590
M V SHANTI SAGAR

JINDAL VARUNA
Dredger

Cargo Ship
4977

4422
3415 INC

FG
Second Officer
(NCV)

Second Officer
02/08/2012

16/05/2012
21/05/2013

05/07/2012
9

1
21

21
Special Category : 1.Trade
Area - Indian Coast,

M V SHANTI SAGAR Second Officer Special Category : 1.Trade

Dredger 4977 3415 INC 05/02/2011 04/07/2011 4 28
IV (NCV) Area - Indian Coast,
Watch Keeping
Deck Officer
SP BOSTON Oil Tanker 4599 3806 FG 23/03/2010 16/08/2010 4 25
OINW or Third
officer
Watch Keeping
Deck Officer
M T JAG PARWAR Oil Tanker 19925 3320 FG 13/02/2009 26/08/2009 6 12
OINW or Third
officer
Second Officer
M T JAG PRAGATI Oil Tanker 18542 2107 FG 15/11/2008 18/01/2009 2 4
(NCV)
Watch Keeping
Deck Officer
M V DS MANATEE Bulk Carrier 42944 FG 15/08/2008 03/09/2008 0 20
OINW or Third
officer
Other Senior
M V SEA LION J Bulk Carrier 10276 FG Deck/Nautical 19/03/2008 30/05/2008 2 13
Officers

E-1 REPORT ON STRUCTURED ON-BOARD TRAINING :

Phase No Date Of Name of Master Details Of Certificate Of Competancy

E-2 REPORT OF DESIGNATED COMPANY TRAINING OFFICER :

Signature :

Name : Certificate No. :

E-3 REPORT OF HEAD OF ASSESSMENT CENTRE :

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 Signature :

Name : Official Stamp :

F. REPORT OF ASSESSMENT CENTRE :

POST-SEA APPROVED EDUCATION AND TRAINING AT APPROVED INSTITUTION LEVEL
2M(Operational)/1M&M(Management)

Function /Part Institution From To Remarks

Indian Maritime University- Mumbai Port Campus (LBS
PHASE2 15-OCT-2020 14-JAN-2021
CAMSAR & MERI)
Indian Maritime University- Mumbai Port Campus (LBS
17-JUN-2019 14-SEP-2019
CAMSAR & MERI)

F-2 REMARKS OF HEAD OF ASSESSMENT CENTRE :

ELIGIBILTY FOR OPERATIONAL/MANAGEMENT LEVEL(Phase I & II)

ELIGIBILITY FOR WRITTEN FUNCTION I/II/III/ASM
ELIGIBILTY FOR ORALS FUNCTION I/II/III/ASM

* Online application may be provisionally approved subject to verification of Originals during Orals
SB/MMD(M)/2019/22231590
Signature :

Name : Official Stamp :

G. PARTICULARS OF STCW CONVENTIONS MODULAR COURSES (POST-SEA) :

STCW Reg. / Period

Sr. Validity
Courses STCW Code Cert. No. Approved Institution
No.
No From To

1 Radar and Navigation Simulator 2070422221230046 MASSA Maritime Academy 06-MAR-2023 13-MAR-2023

2 Medical Care A-VI/4-2 20100164212300315 BP Marine Academy 11-FEB-2023 22-FEB-2023

Advanced Training for Oil Tanker Cargo Yak Management And Marine
3 TASCO/07/011/05/16 04-JUL-2016 14-JUL-2016
Operations Education Centre

Advanced Training for Chemical Tanker Yak Management And Marine

4 CHEMCO/06/013/16 20-JUN-2016 30-JUN-2016
Cargo Operations Education Centre

5 Refresher Training for Medical First Aid 3B7659C6FD4B791 Naval Maritime Academy West 08-MAY-2015 08-MAY-2015

6 Personal Safety & Social Responsibilities A-VI/1-4 D483D7739678A2D6 Naval Maritime Academy West 27-APR-2015 29-APR-2015

Electronic Chart Display and Information Anglo Eastern Maritime Training

7 1061 20-APR-2015 24-APR-2015
Systems Centre

Refresher Training For Proficiency In PSCRB

8 B183EA8B95903A91 Naval Maritime Academy West 18-APR-2015 18-APR-2015 17-APR-2020

Refresher Training for Advanced Training in

9 A5C653F1AC195590 Naval Maritime Academy West 15-APR-2015 15-APR-2015
Fire Fighting

10 Ship Security Officer 31572800A0979E58 Naval Maritime Academy West 12-DEC-2013 14-DEC-2013

11 Advanced Training in Fire Fighting A-VI/3 0020450162007 TS Rahaman 19-NOV-2007 24-NOV-2007

12 Automatic Radar Plotting Aids A-II/1 ARPA/0160/021/07 Naval Maritime Academy West 05-NOV-2007 09-NOV-2007

13 Radar Observer Simulator A-II/1 ROSC/0146/019/07 Naval Maritime Academy West 22-OCT-2007 01-NOV-2007

14 Personal Survival Techniques A-VI/1-1 PSTC/1330/107/2002 Naval Maritime Academy West 14-NOV-2002 16-NOV-2002

MFAC/0639/044/2002
15 Medical First Aid A-VI/4-1 Naval Maritime Academy West 04-NOV-2002 07-NOV-2002

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H. PREVIOUS CERTIFICATE ( Issued in India or elsewhere, If none state so) :
If any time suspended or cancelled, state
Place & date of Examination
Number Certificate
Class /Grade
Details Examination Issue Date
Court of Authority
Date Cause
Second Mate of a Foreign Going 24-MAY-2016
1 IF-34706
Ship
MUMBAI
Navigational Watch Keeping
2 NCV-1033
Officer(NCV)
MUMBAI 24-FEB-2010

I. DECLARATION TO BE MADE BY THE CANDIDATE :

I hereby declare that the particulars contained in the form are correct and true to the best of my knowledge and belief
and that the papers enumerated and sent with this form are true and genuine documents given and signed by the person
whose name appears on them. I further declare that Section D contains a true and correct account of my sea-going service
without exception and I make this declaration conscientiously believing the

SURENDRA SINGH The above declaration was signed in my presence.

Signature of the candidate Examiner of Masters and Mates

Mercantile Marine Department.........................District

J. REQUEST FOR ALLOTMENT OF SEATS FOR EXAMINATION :

Sign of

SB/MMD(M)/2019/22231590
Sign of
Fees Paid Written Papers Orals Candidate
Examiner
Applied
Month Grade
for
Referance No CARGO CARGO/
Amount NAV1 NAV2 NAV3 NAV4
/ ASM
SOF1 SOF2 NAV
ASM
SOF
& Date

QUR280020694
MMD OCT-2019 CHIEF
MATE
6000 49 20/09/2019 Y Y Y Y Y
MUMBAI

RAXG83173357
MMD CHIEF
JAN-2020
MATE
6000 06 18/12/2019 Y Y Y Y
MUMBAI

SSBI926953556
MMD OCT-2020 CHIEF
MATE
1500 2 28/09/2020 Y
MUMBAI

VAXG97628712
MMD MAR-2021 CHIEF
MATE
6000 73 19/02/2021 Y Y Y
MUMBAI

WUR203502387
MMD NOV-2021 CHIEF
MATE
6000 68 18/10/2021 Y Y Y
MUMBAI

WUR205298911
MMD CHIEF
JAN-2022
MATE
4500 18 22/12/2021 Y Y
MUMBAI

WUR209310733
MMD MAR-2022 CHIEF
MATE
1500 02 24/02/2022 Y
MUMBAI

YAXG14351951
MMD OCT-2022 CHIEF
MATE
1500 02 26/09/2022 Y
MUMBAI

Y162151454646
MMD NOV-2022 CHIEF
MATE
4500 7 21/10/2022 Y Y
MUMBAI

Y162168258425
MMD CHIEF
FEB-2023
MATE
3000 3 18/01/2023 Y Y Y
MUMBAI

YUR318350530
MMD MAY-2023 CHIEF
MATE
3000 28 11/04/2023 Y Y Y
MUMBAI

YUR319038463
MMD CHIEF
JUN-2023
MATE
3000 84 24/05/2023 N
MUMBAI

K 1. Sight Test :Date of Examination : _________________Result _____________Signature of Examiner

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K 2. RESULT OF EXAMINATION :( for official purpose only) :

Name of Examiner
No. Written Papers Orals Signal
of O : Oral , W :Written
Atte Month Grade
mpts CARGO/ CARGO/
NAV1 NAV2 NAV3 NAV4 SOF1 SOF2 NAV SOF
ASM ASM

OCT-2019 CHIEF PASS FAIL FAIL FAIL

1 FAIL (PHS1)
MATE (PHS1) (PHS1) (PHS1) (PHS1)

CHIEF FAIL PASS FAIL

2 JAN-2020 FAIL (PHS1)
MATE (PHS1) (PHS1) (PHS1)

OCT-2020 CHIEF ABSENT

3
MATE (PHS1)

MAR-2021 CHIEF FAIL FAIL

4 PASS (PHS1)
MATE (PHS1) (PHS1)

NOV-2021 CHIEF ABSENT PASS ABSENT( ABSENT FAIL

5
MATE (PHS2) (PHS2) PHS2) (PHS2) (PHS2)

5
SB/MMD(M)/2019/22231590
NOV-2021 CHIEF
MATE
PASS
(PHS1)
ABSENT(
PHS2)
FAIL
(PHS1)

CHIEF FAIL FAIL FAIL

6 JAN-2022
MATE (PHS2) (PHS2) (PHS1)

CHIEF FAIL FAIL

6 JAN-2022
MATE (PHS2) (PHS1)

MAR-2022 CHIEF PASS(PH

7
MATE S2)

OCT-2022 CHIEF FAIL

8
MATE (PHS2)

NOV-2022 CHIEF ABSENT FAIL PASS

9
MATE (PHS2) (PHS2) (PHS1)

NOV-2022 CHIEF ABSENT PASS

9
MATE (PHS2) (PHS1)

CHIEF FAIL PASS FAIL

10 FEB-2023
MATE (PHS2) (PHS2) (PHS2)

MAY-2023 CHIEF
11
MATE

CHIEF
12 JUN-2023
MATE

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Note :
Second Mate (FG) / NWKO-NCV : NAV 1: Terrestrial and coastal Navigation, NAV 2: Celestial Navigation, NAV 3: Meteorology, NAV 4: Bridge Watch Keeping and Emergencies.

First Mate (FG / NCV ): Phase I: NAV 1:Terrestrial and coastal Navigation. NAV 2: Meteorology, SOF 1: Ship Safety, Damage Control and Management of Personnel, SOF 2: Naval
Architecture Paper I.

First Mate (FG / NCV ) Phase II: NAV 1: Navigation AIds Including compasses, NAV 2: Bridge Watch Keeping . Ship Handling and Emergencies , NAV 3: Engineering Knowledge ,
Instruments and Control Systems , SOF 1: Naval Architecture Paper II, SOF 2: Marine Legislatoin .

L. REPORT OF EXAMINATION CENTRE

1. I hereby certify that Surendra Singh has satisfactory produced testimonials and proof of sea-going service/watch
keeping service/approved workshop training as required for the grade.

2. The candidate complies with the examination of the Merchant Shipping Standards (Standards of Training
Certification and Watch-keeping for Seafarers) Rules, 1998 for the grade of First Mate of a Foreign Going Ship

3. The candidate has passed his examinations for the functions as under :

Function
Phase Level
Written Written Examiner Oral Oral Examiner
OCT-2019
PHASE1 NAVIGATION Assessment officer
MMD MUMBAI
NOV-2022
PHASE1 SHIP OP. Assessment officer
MMD MUMBAI

SB/MMD(M)/2019/22231590
M. FOR THE CHIEF EXAMINER OF MASTERS AND MASTES

1. I hereby certify that Surendra Singh born at Gangrani on 13.03.1969 has satisfactory produced his testimonials and
proof of Sea-going Service/Watch Keeping Service.

2. The candidate complies with the Merchant Shipping (Standards of Training Certification and Watch-keeping for
Seafarers) Rules, 1998 for the grade of First Mate of a Foreign Going Ship

3. The candidate has passed the examination of the functions as under :

Phase Level Function Sign. of Examiner with Remarks

Written Oral
OCT-2019
PHASE1 NAVIGATION
MMD MUMBAI
NOV-2022
PHASE1 SHIP OP.
MMD MUMBAI
The candidate meets the requirements be eligible to be issued the Certificate of Competency as ...............................................
provisional certificate issued No.................................................................... on....................................................................

Examiner of Masters and Mates

Mercantile Marine Department

N. FINAL ASSESSMENT PRIOR CERTIFICATION

Medical Fitness

Pre-Sea Training Complied

Structured on Board Training N/A

Sea-Service Requirement Complied

Written Examination (Assessment) Yes

Oral Assessment Yes

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 Modular Courses Complied

Eligibility Yes

Certificate for Competency First Mate of a Foreign Going Ship as recommended by Mercantile Marine Department may be issued.

Assessor at Directorate General of Shipping for Masters and Mates.

Remarks_____________________________________________________________________

Chief Examiner
(Masters and Mates)

SB/MMD(M)/2019/22231590

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