SAMUNDRA INSTITUTE OF MARITIME STUDIES

SIMS Application Form

Please choose the course you wish to apply for
DNS Feb/Aug 2012
*Applicant must not be more than 20 years old (for class XII) 25 years old (for B.Sc. in PCM or
Electronics) and 25 years old (for BE / B.Tech Degree from I.I.T or a college recognized by AICTE)
as on the date of commencement of course Feb/Aug 2012.

GME Mar/Sept 2012

*Applicant should be a BE/ B.Tech Mechanical Engineering and must be not more than 25 years old as on the date of commencement
of course Mar/Sept 2012.

B.Tech (Marine Engineering) Aug 2012

* Applicant must not be more than 20 years old and Passed in 10+2 or equivalent exam with Physics, Chemistry, Mathematics and
English as separate subjects with PCM average not less than60% as on the date of commencement of course Aug 2012.

(Application form must be filled by the candidate himself)

A. Personal Data (*Please delete accordingly)
1. Full Name (please fill in BLOCK letters) : __________________________________
Family Name:
______________________________________
First Name:
______________________________________
Middle Name:
______________________________________
2. Date of Birth (dd/mm/yyyy):
__/__/____
Age (As on the date of commencement of course):
Place of Birth:
____________________
Citizenship:
____________________
3. Mailing Address:
Telephone No with STD code:
E-mail Address:

___Years ___Months

___________________________________
City______________ State_____________
Pin_______________
___________________________________
___________________________________

4. Permanent Address: Same as Above

If not, please provide details: ______________________________________
City______________ State_____________
Pin_______________
Telephone No with STD code: ___________________________________
5. Martial Status: ___________________
6. Height:
Weight:
Identification Mark:
Eyesight:
Color Blindness:

_____cm
_____kg
______________________________
______________________________
______________________________

7. Any major illness/operations undergone before? Yes / No

If Yes, please provide details :
_______________________________________________________________________________________

8. Fathers / Guardians Name*:

_______________________________________
Occupation:
_______________________________________
Office Address:
_______________________________________
Office Tel No with STD code:
_______________________________________
E-mail Address:
_______________________________________
Annual income of parents: Rs.
______________
9. Any family members/relatives previously and/or currently employed by Executive Ship Management Pte.
Ltd or Samundra Institute of Maritime Studies? Yes / No
If Yes, please provide his/her/their name(s) and designation(s):
_____________________________________________________________________
_____________________________________________________________________
10. Details of Siblings: (Brothers & Sisters, Occupation, Educational qualifications)
(Provide details separately if space is insufficient)
____________________________________________________________________________________________________
__________________________________________________________________________________
B. Academic Qualification:
1. Name of High School attended: _______________________________________
Board:
_______________________________________
Address:
_______________________________________
2. Years of Education: From _______ (yyyy) To _______ (yyyy)
3. Year of passing X Standard: _______
4. Percentage of Marks Obtained (Class X):
Passed in First Attempt?
Yes / No
a) Total:
_______ %
b) Science:
_______ %
c) Mathematics: _______ %
d) English:
_______ %
5. Name of Junior college / HSC / 10 + 2 attended : _____________________
Board: _______________________________________
Roll Number of Board Examination: _______________________________________
Address: ______________________________________________________
______________________________________________________
6. Years of Education: From _______ (yyyy) To _______ (yyyy)
7. Year of passing XII Standard: _______
8. Percentage of Marks Obtained (Class XII):
Passed in First Attempt? Yes / No
a) Total:
_______ %
b) Physics:
_______ %
c) Chemistry:
_______ %
d) Mathematics: _______ %
e) English:
_______ %
9. Details of Scholarship/ Award / Merit obtained, if any:
(Provide details separately if space is insufficient)

______________________________________________________________________________________
______________________________________________________________________________________
B. Academic Qualifications:
Graduation Details (Optional, to be filled by candidates having B Sc/ BE/ B Tech Degree)
Name of College/Institute: ____________________________________________
Passed in First Attempt: _________________________ _
University: __________________________________________________
Roll Number of University Examination: _______________________________
Address: _________________________________________________________
Years of Education: __________________
Year of Graduation: ______________________________\
Please CHOOSE either one of the following to fill
Percentage of Marks Obtained BSc ONLY if applicable
Total % : __________
BSc 1st Year %:_______________ BSc 3rd Year % :___________________
BSc 2nd Year %:_______________ English % :___________________
Percentage of Marks Obtained BE/B TECH ONLY if applicable
Percentage of Marks Obtained %:__________English %:____________
Semester I %: ________________ Semester V %: _________________
Semester II %: ________________ Semester VI %: _________________
Semester III %: ________________ Semester VII %: _________________
Semester VI %: ________________ Semester VIII %: _________________
IIT-JEE Details (Optional)
Roll No : ________________
Rank : ________________
Qualified for counseling: Yes / No
AIEEE Details (Optional)
Roll No ________________
Rank : ________________
Marks for paper 1 : ________________
Marks for paper 2 : ________________
Qualified for counseling : Yes / No
C. Extra curricular Activities:
(Provide details separately if space is insufficient)
1.
2.
3.
4.
5.
6.

Participation in NCC, Boy Scout etc.: ______________________________________

Participation in Sports: __________________________________________________
Participation in Debate, Quiz, Elocution competition:__________________________
Participation in Project work, Science Exhibition etc:__________________________
Hobbies: _____________________________________________________________
Write on Why I want to join Merchant Navy in not more than 100 words.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

D. Others

1. Please indicate TWO preferred locations for the interview should you be selected for it. State your first and
second choice by filling 1 and 2 in the boxes provided next to the location.
Mumbai Chennai Cochin Chandigarh Delhi Kolkata Guwahati
2. Any other information you want to tell us about yourself?
_____________________________________________________________________
3. How did you come to know about Samundra Institute of Maritime Studies, Lonavla?
(You may select more than one option.)
Family/Relatives/Friends
School/College
Brochures
Internet
Newspapers/Magazines, please provide name:_________________________
Others, provide details:___________________________________________
E. Examination Centres
Examination venues will be announced by respective Exam Centers.
Delhi ESM Field Office
Executive Ship Management Pte Ltd
502A, Rectangle -I, D-4,
District Centre, Saket,
New Delhi 110017
Tel: + 91-11-29562775/6/8
Fax: + 91-11-2956-2777
Email: [email protected]

Chandigarh ESM Field Office

Executive Ship Management Pte Ltd
S.C.O. 427/ 428 (1st Floor)
Sector 35-C, Chandigarh - 160022
Tel: + 91-172-4023700/2600417
Fax:+ 91-172-264-5417
Email: [email protected]

Chennai ESM Field Office

Executive Ship Management Pte Ltd
Batra Centre 1st Floor
No. 28, Sardar Patel Road
Guindy, Chennai 600032
Tel: + 91-44-30453300
Fax:+ 91-44-30453341
Email: [email protected]

Cochin ESM Field Office

Executive Ship Management Pte Ltd
Kochi Liaison Office,
OS-21 3rd Floor,
GCDA Shopping Complex,
Marine Drive, Kochi-682 031
Tel: + 91-484-3259591/3219591/2367275
Fax:+ 91-484-2367275
Email: [email protected]

Mumbai ESM Field Office

Sai Commercial Annexe,BKS Devshi Marg
2nd Floor, Govandi Station Road
Govandi (East)
Mumbai, Pin 400088
Tel Nos: + 91-22-67551700/67993540
Fax Nos: + 91-22-67551771
Email: [email protected]

Kolkata ESM Field Office

Executive Ship Management Pte Ltd
Unit 604, 6th floor, Jasmine Tower,
No.31, Shakespeare Sarani,
Kolkata 700017.
Tel: + 91-33-32520777/40084577
Mobile: + 91-9831957177
Email: [email protected]

ESM Patna Field Office

Executive Ship Management Pte Ltd
211, 2nd Floor,
Sisodia Palace, Gorakhnath Compound,
Patna - 800 001
Tel: +91-612-2532124 / +91-612-6530634
Email: [email protected]

Dehradun Field Office

Executive Ship Management Pte Ltd
Opposite Premier Complex, 1st Floor
Adjoining State Bank of India Kaulagarh Road,
Rajender Nagar, Dehradun India 248001
Tel: +91 135 2751827, Fax: +91 135 2751827
Mobile: +91 9997997445
Email: [email protected]

F. Interview Location
Examination / Interview dates will be announced by representative centers and details will also be updated in
the website.

G. Terms of Application
All related costs incurred as a result of the short listed applicant attending the interview, including cost of
medical tests and psychometric test, shall be borne by the applicant himself.
The list of successful candidates who are accepted for SIMS pre sea training, would be announced in our
website. These candidates are to submit a non-refundable joining fee, except for caution fee which will be
refunded after adjusting any dues, as per the schedule date stated in our website. Failure to pay the joining fee
within the time frame, would indicate non-acceptance of the offer.
H. Declaration by the Applicant
I declare that all information provided in this form, is true and complete in all respect. I fully understand that
any misrepresentation or omission of information may be considered sufficient for withdrawal of the offer and
dismissal from the course at any time. I also agree to the terms set out in Section G.
I confirm that the information as set out in this application were provided by me and that the said information is
true and correct.
I understand that I may be subject to prosecution if I have provided any information, which is false in any
material particular or is misleading by reason of the omission of any material particular.
Further I, ______________________________ declare
1. I shall not engage in or participate in any business or be self-employment during my training at SIMS.
2. I shall not misuse controlled drugs or take part in any political or other illegal activities during my stay
in SIMS premise.
3. I have not submitted any false statement or submitted any document which I know to be false in order to
obtain the admission at SIMS.
4. I confirm that my candidature is purely on my merit and does not involve any recommendations.
5. I have not bribed any one in ESM, SIMS, Agent, or outside agencies to get my admission at SIMS.
I understand that if I breach any conditions above, during training at SIMS or even after training at SIMS, I will
be subjected to
1. Prosecution in court
2. Dismissal and pay all costs including Training fees if it is during training at SIMS prior employment
onboard.
3. Immediate dismissal from the ship and I agree to pay SIMS:a. all the cost incurred for my repatriation
b. all the costs incurred for my relievers joining ship
c. all the costs incurred, including training fee for my pre-sea training SIMS
d. all the costs incurred for my post-sea training at SIMS
__________________________
Signature of Candidate

__________________
Date

Please send the completed application on below mentioned address.

Samundra Institute of Maritime Studies(SIMS), Lonavla
Village Takwe Khurd, Mumbai Pune Highway(NH-4),
Lonavla, Dist. Pune, Maharashtra 410405.
Tel: 91-2114-399500/517 Email: [email protected]
For Official Use Only:
Status: 1 / 2 / 3
Comments:
_________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________________________________________________
Assessors Name: ____________________Signature of Assessor: __________________