Short Voyage

To,

wkwcs gv÷vi,

PÆMÖvg|

The Shipping Master

Chittagong.

 

g‡nv`q,

Sir,      

            Avgv‡K kU© f‡qR †ewbwdU/Pvi erm‡ii evav cÖZ¨vnv‡ii Rb¨ Aby‡iva Kwi‡ZwQ Ges cÖ‡qvRbxq Z_¨vejx wb‡¤œ cÖv`vb Kwi‡ZwQ|

            I request for short voyage benifit/four years band withdraw and furnish the required particulars as under.

 

 

 

1|

bvg .........................................................

Name

(eo Aÿ‡i)

(In Capital letters)

2|

(K)

wcZvi bvg .................................................

Father’s Name

(L)

gvZvi bvg .................................................. Mother’s Name

3|

Rb¥ ZvwiL

Date of Birth ................................................

 

4|

RvZxqZv

Nationality .............................

 

5|

†kl RvnvR Qvovi ZvwiL

Date of Last Discharge ..............................

6|

c`‡f`

Category ...................................

7|

wmwWwm bs

CDC NO. ....................................

 

8|

e›`i ¯^v¯’¨ Kg©KZ©vi Wv³vix mb` bs-

 Medical Cert. No. .......................................

 Wv³vi KZ©„K cixwÿZ nIqvi †kl ZvwiL

 Last Date of Examined .................................

 

 

9| evoxi c~Y© wVKvbv wVKvbv

     Home Address(in full)

 

MÖvgt-

Village

WvKNit-

P.O.

_vbvt-

Thana

wRjvt-

District

 

BDwbqbt-

Uninion

 

10| eZ©gvb wVKvbv

     Present Address

 

 

11| cÖwkÿ‡bi weeibt-

mb‡`i mswÿß bvg

Bm¨yi ZvwiL

(K)

 

 

(L)

 

 

(M)

 

 

(N)

 

 

(O)

 

 

 

 

 

 

 

 

12| eZ©gvb †ivóv‡ii bvg I ZvwjKv fyw³i ZvwiLt-

13| kU© f‡qR/Pvi eQ‡ii evav mswÿß Kvibt-

 

 

 

Avwg `„pZvi mwnZ ewj‡ZwQ †h Dc‡iv³ Z_¨vejx mZ¨,

I affirm that the particulars furnished above are correct.

 

ZvwiL

Date:-

 

 

Av‡e`bKvixi ¯^vÿi/wUcmwn

   ‡gvevBj bs-

Signature of the Application

   Mobile No.-

(miKvix wkwcs Awdm KZ©„K cyib Kiv nB‡e)

(To be filled by Shipping section)

wkwcs kvLvi gZvgZ(kU© f‡q‡Ri Kvib)t- Dc‡iv³ bvweK wb‡Ri Kvi‡b /†Kv¤úvbxi Kvi‡b /¯^v¯’¨MZ Kvi‡b /AvnZ nIqvq /Ab¨vb¨ Kvi‡b ............ Bs nB‡Z......................Bs ch©šÍ †gvU ................w`b kU© f‡qR K‡i‡Qb|

ZvwiLt-

 

‡ivóvi kvLvi gZvgZt- Av‡e`b Kvixi kU© f‡qR †ewbwdU/Pvi eQ‡ii evav cÖZ¨vnvi Kiv †h‡Z cv‡i/cv‡ibv|

Kg©KZ©vi gZvgZt- †ivóvi kvLvi gZvgZ MÖnb Kiv †h‡Z cv‡i /cv‡i bv|

 

kU© f‡qR †ewbwdU/Pvi eQ‡ii evav cÖZ¨vnv‡ii Aby‡iva Kiv nBj|

Short voyage benefit/four years hand withdraws Allowed.

ZvwiLt-

 

 

 

wkwcs gv÷vi

Shipping Master, Chittagong.