ORISSA MARITIME ACADEMY

At/Po: Paradip Port, Orissa-754142

APPLICATION FORM FOR PRE SEA G. P. RATING COURSE

Index No. For

Office use only. Affix Passport
size
Photograph
here
To be filled in Capital letters only.
1. Name of Candidate (as written in Board Certificate)

2. Name of Father or Mother or Guardian

P I N

3. Address:
With name of state

4.Contact Telephone No.

&
Mobile No

5. If ST/SC write YES

6. Date of birth D D M M Y1 Y
9
Examination Year of Aggregate % marks Name of
7. Percentage of marks passed Passing % In English Board/University
Obtained in 10th pass 10th pass
(& in +2 Levels, if any).
+2 Level

Others
8. Height in Centimeter Weight in Kgs.

9. Do you have any chronic ailment If yes, please specify.

10. Occupation of Father

11. Occupation of Mother
12. Do you have any of relatives associated with shipping field? If yes specify-

13. Enclosed DD/bank counter foil Amt Rs.200/- as application fees No. Dated:

Place:
Date: Signature of Applicant
Note:1. Before applying make sure;
a) Your age is between 17 ½ yrs & 25 Yrs and Eye sight is Normal
b) You have minimum 40% aggregate in 10th standard & 40 % in English in 10th or in +2.
c) Attach attested copies of your certificates.

Note 2:d) We will not reply to ineligible candidates.

e) See our website www.orissamaritime.com for selection list
f) Our Bank: ALLAHABAD BANK, PARADIP BRANCH (ORISSA)
SB A/C no. 20219850316