MMB Application Form 06 12 2021 1

Maharashtra Maritime Board (MMB) Examination
FORMAT- IV- 01
Fresh Candidate’s Application Form DATE: 06.12.2021
REV No.: 6
(as per I.V Act’ 1917)
Roll Number
Through “Board of Examinations for Seafarers Trust”
Note: (i)Division (A), (B), (C), (D), (E), (F), (G) (H)& (I) of this application form are to be filled by the applicant & submit
to BES office with candidate’s Testimonials and former Certificate, if any.
(ii) Entire form is to be filled in “CAPITAL LETTERS” only.
(A) Tick mark (√)for the grade to be examined

Engine Side Deck Side Signature of Candidate Paste your recent
pass port size
2nd Class 1st Class Engineer Serang 2nd Class 1st Class
Engine Engine of Inland Master Master photograph Colour
Driver Driver Vessel (30mm x 40mm)
Background Plain
White / off White
(B) Candidate’s details

Name in full-
Nationality - Educational qualification-
DD MM YY Place of Birth (Village) Police Thana District State

D.O.B
Permanent Address
(with Village, Police

Thana, Post, District
and State)
District State PIN
Present Address
(with Village, Police

Thana, Post, District
and State)
District State PIN
Mobile No.
Email - ID
Tick mark (√) on preferred language Marathi Hindi English
for appearing Examination
(C) Personal Description of the Candidate
Height in
Identification Mark
Centimetres
(D) Particulars of all previous certificate copies (if any) to be submitted:-

Number Certificate of Grade Where Date of If at any time Date Cause
Competency issued Issue Suspended or cancelled, state
by which court or authority
MMB Examination as per IV Act’ 1917 Page 1 / 3

(E) Attach self-attested copy of the following document / certificate:
(a) Valid Passport OR Police Clearance Certificate
Note: Candidates who are working in the Government Organization, PSUs and Major Port
Trust must forward their Application with the “No Objection Certificate” from his/her Head
of the department. Such candidate may not submit Police Clearance Certificate.
(b) Copy of the following documents:

1. Govt. issued Photo Identity Card such as Voter Card, Driving Licence, MMB Card, etc.
2. School leaving Certificate (SLC) OR Birth Certificate
(F) Details of DD made in favour of ‘Board of Examinations For Seafarers Trust’ as

Assessment Fee:
DD No. DD Date Amount of DD Name of Bank with Branch Name
(G) List of Documents / Certificates to be attached:

1. Original Sea Service Certificate
2. Original Notarized Affidavit
3. Other State “Serang” Certificate holder - Original Letter from IV Master / Company certifying that the
candidate has worked under duly qualified IV master of vessel plying within the coast of Maharashtra
4. Self-attested copy of Educational Qualification Certificate
5. Self-attested copy of valid Passport OR Police Clearance Certificate OR If NOC, then in Original
6. Self-attested copy of Govt. issued Photo Identity Card
7. Self-attested copy of School Leaving Certificate (SLC) OR Birth Certificate
8. Self-attested copies of Modular Safety and Security Courses
9. Valid DG Approved Medical Certificate as mentioned in Eligibility Criteria.
(H)
To take notice that any person who makes, procures to be made or assists in making of any false representation
for the purpose of obtaining for himself or any other person a Certificate of Competency is for each offence liable
to be punished for a misdemeanour. I do hereby, declare that particulars contained in division (A), (B), (C), (D),
(E), (F), (G) and (H) are correct and true to the best of my knowledge and belief , and that the documents
enumerated in division (G) and sent with this form are genuine, given and signed by the person whose names
appear on these documents . I further, declare that the statement (H) contains a true and whole of my service
without exception. And I make this declaration consciously believing it to be true.
Dated: _________________
_____________________
Place: __________________ Signature of the Applicant
(J) For Assessing Officer’s Use Only:
Applied Clause for Eligibility Signature:

Eligible / Not eligible
Date :

(K) For Office Staff Use Only:
Name of the Candidate
Candidate’s Roll No.
Grade Appearing
(L) For Examiner’s Use Only:
Note: The Examiner should fill up following field and in all cases as soon as possible forward this
paper to the Chief Co-ordinator IV examination, Navi Mumbai. If the applicant passes his
Testimonials and previous Certificate if any must be sent with this paper to the Co-ordinator of IV
examination.
Part – I
Date of Written Examination Written Examination Result
Pass or Fail
Part – II
Specify Rank for which passed
Date of Oral Examination Oral Examination Result
Pass or Fail Rank Passed___________________
Examiner’s Signature____________
Date: ________________________
(M) For Examination Co-ordinator’s Use Only:

I hereby, certify that the particulars contained above are correct. The above-named candidate has been
Declared FINALLY (Pass or Fail) ________________.
Dated this ------------------------ day ----------------- of ----------------------
Co-ordinator (IV Examination)

Board of Examination for Seafarers Trust
CBD Belapur, Navi Mumbai.

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Maharashtra Maritime Board (MMB) Examination

(A) Tick mark (√)for the grade to be examined

(B) Candidate’s details

Nationality - Educational qualification-

DD MM YY Place of Birth (Village) Police Thana District State

(with Village, Police

(with Village, Police

(D) Particulars of all previous certificate copies (if any) to be submitted:-

MMB Examination as per IV Act’ 1917 Page 1 / 3

(b) Copy of the following documents:

(F) Details of DD made in favour of ‘Board of Examinations For Seafarers Trust’ as

(G) List of Documents / Certificates to be attached:

(J) For Assessing Officer’s Use Only:

Applied Clause for Eligibility Signature:

MMB Examination as per IV Act’ 1917 Page 2 / 3

Name of the Candidate

Candidate’s Roll No.

(L) For Examiner’s Use Only:

(M) For Examination Co-ordinator’s Use Only:

Dated this ------------------------ day ----------------- of ----------------------

Co-ordinator (IV Examination)

MMB Examination as per IV Act’ 1917 Page 3 / 3

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