Application Form

Important : please ensure that all coulmns are filled up for acceptance of this application by office of The Maritime Union of India.

MUI Membership No. * :

Name In Full (BLOCK LETTERS - surname first) * :

Date Of Birth * :

Place Of Birth * :

Perment Address For Correspondence * :

Grade, Number An Complete Description Of Certificate * :

Date And Port Of Issue * :
(a) INDOS No.

Has your Certificate ever been
(a) Suspened?
(b) Cancelled?
(c) Successfully defended in an
(d) official Enquiry?
If so, please give particulars *

Have you ever been in a ship that has met with an accident in respect of which there has been an official enquiry?
If so, please give pariticulars *

Name Of Your Present Ship *

In What Capacity Are You Now Serving? *

Name Of Owners/Agent *

How Long Have You Served With Them? *

DECLARATION

I hereby declare that the above details are in every reapect true and correct, and that I have not withheld any information calculated to influence the decision in regard to this proposal.
I pay here with the sum of RS.200/- being the first application cost and agree to renew it every year.

CERTIFICATE INSURANCE APPLICATION

DECLARATION