ANGLO EASTERN GROUP Declaration Form Please also complete the Documentation checklist AEI-FPD-03, issued as an attachment with this form.

Name

Rank applied

Available From

General Declaration Sr

During your tenure onboard vessel …

YES

NO

YES

NO

Incidents of Grounding/Fire/Explosion/Collision/Abandon Ship/Rescue/ Major Oil Pollution /Drug Smuggling/Towed or Towing another

1

vessel.

2

Were you ever involved in a Court of Enquiry for a Maritime accident?

3

Have you ever missed your ship or left behind in port?

4

Has your present or previous certificate ever been suspended/revoked?

5

Have you ever been involved in a criminal proceeding?

6

Have you or your vessel ever been accused of MARPOL violation?

7

Have you ever been refused VISA or been deported from any country, or have a case of FEMA violation / Custom cases against you.

8

All Documents held by you are genuine and are obtained by you through official channels and not through any agency.

9

Have you been asked for favours in kind or cash for gaining employment in AESM?

If yes on any of the above, or No on point 8,then give details:

Medical History & Declaration Height (mtrs)

BMI = Weight (KG)

(Wt in Kg)

Blood Group

2

(Ht in mtr)

Sr.

Medical Declaration

1

Do you suffer or have suffered from: Diabetes/High Blood Pressure/ Hepatitis/ Epilepsy/Nervous Disorders /Disturbed Vision or Hearing/Vertigo .

2

Are you under regular medication for any ailment?

3

Are you a habitual user of Drugs/Narcotics/Excessive Alcohol OR have failed a Drug n Alcohol Test ?

4

Are you aware of any ailment that would make you unfit for sea service:

5

Have ever meet with an accident or signed off on medical grounds

6

Have you been operated for any ailment in the past 10 years

If yes on any of the above, give details:

Declaration to be made and signed by Applicant: I hereby confirm that the information given by me is true and factual to the best of my knowledge and belief and that I have not withheld any information that would make my application unfavourable. I understand that a strict medical examination including Drug and Alcohol test as per company requirements is a condition of my employment and I express my willingness to be examined. I undertake to provide the Company’s medical officer full details of my previous medical history. I agree that the decision of the Company’s medical officer is final. I confirm that all my travel documents are valid and in order. I understand that if my travel documents at any time during the course of my employment become invalid or restricted and cannot be revalidated by me under normal process, making further travel or service by m e is not possible, the contract of employment stands subject to cancellation and all costs of repatriation will be borne by me. I am/am not presently committed to any other company.

Date:_____________________

Form : AEI-FPD 02

Place: _________________

Revision : 2

Signature of Applicant : _____________________

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Issue date : 15 May 12