Tolani Maritime Institute
Induri,Talegaon Dabhade, Pune - 410507
Tel.: 02114-669600/1, E-mail: admissions@tmi.tolani.edu, Web: www.tolani.edu
Electro-Technical Officers Course
(Pre-sea Training & Certification for Merchant Ships)

APPLICATION FOR ADMISSION - October 2021


Application Summary
 
Dossier ID: ETO2167338 Name: PEREIRA SAMSON ANDREW CAESAR
  Address: HOUSE NO. 32 NEAR CARMELITE MONASTERY
Telephone No.: Mobile no: 9960548381
E-mail: samson.pereira4@gmail.com  
   
Application fee payment details:  
Payment Status: Paid Payment Mode: Online
Amount: ₹ (Includes Convenience fee of ₹ ) DD Number: -
Issuing Bank: - Transaction Id: -
   
   
Declaration: We hereby declare that all the statements made in application form against Dossier ID ETO2167338 are true and correct.
Signature of Candidate Signature of Parent/Guardian
   
   

___________________

___________________

   
Date ________________ Date ________________
 

 

Please quote your dossier id and full name for any future correspondence
Please keep a copy of the form for your reference for communicating with the Institute.
Institute will communicate with you once the form is submitted and online payment is done successfully. Please keep all your academic certificates & Annex-I ready with you.

     
     

Tolani Maritime Institute
Induri,Talegaon Dabhade, Pune - 410507
Tel.: 02114-669600/1, E-mail: admissions@tmi.tolani.edu, Web: www.tolani.edu
Electro-Technical Officers Course
(Pre-sea Training & Certification for Merchant Ships)

APPLICATION FOR ADMISSION - October 2021

Dossier ID: ETO2167338
 
Full Name (as per Passport) : PEREIRA SAMSON ANDREW CAESAR
Date of Birth (DD/MM/YY): 30 Nov 1996 Nationality: INDIA
Gender (M/F): Male Marital Status (Single/Married): Single
Passport No.: L4843621 Date of Expiry: 22 Sep 2023
Place of Issue: PANAJI Personal Identification Mark: BIRTH MARK ON RIGHT ARM

(Note: If you do not have passport, you may apply for it as early as possible as passport is required for obtaining Seaman’s Discharge Certificate, mandatory for boarding a ship.)

Addresses & Contact Details -

House / Building No.: HOUSE NO. 32
Street /Lane: NEAR CARMELITE MONASTERY
Village / Post Office / Tehsil: PAJIFOND
City / District: MARGAO
State: Goa
PIN: 403601
Telephone No. with STD code: 08322861106 Mobile: 9960548381
E-mail: samson.pereira4@gmail.com  
 

Academic Record -

 
Class X: - Class XII: -
Year of Passing: 2012 Year of Passing:
Board: Goa Board:
English %: 55 English %:
Aggregate Percentage: 61 Aggregate Percentage:
   
Details of Marks Secured in (10+2) Examination -

SUBJECTS MAXIMUM MARKS
MARKS SECURED PERCENTAGE (%)
Physics
Chemistry
Mathematics
English
Physics, Chemistry & Mathematics combined Percentage:
   
   

Diploma:

Graduation:
Diploma Specialization: Electronics Engineering Degree Specialization: Electronics and Telecommunication Engineering
Name of Polytechnic: Agnel Polytechnic Verna Name of College: DON BOSCO COLLEGE OF ENGINEERING
Tel. No.: 2791206 Tel. No.: 2743944
Email Id.: agnelpoly@agnelpolytechnic.org Email Id.: dbcefatorda@dbcegoa.ac.in
Board: BOARD OF TECHNICAL EDUCATION University: GOA UNIVERSITY 
Year of Joining: 2012
Year of Joining: 2016
Year of Passing: 2015 Percentage: 67 Year of Passing: 2019 Percentage: 57
Medium of Instruction: ENGLISH Medium of Instruction: ENGLISH

Note: Diploma/Degree courses must be recognised by any State or Central Government or the AICTE.

Other Qualification, if any -

Work Experience, if any -

Name of the Firm Designation From To
HINDUSTAN BIJLEE SERVICE ENGINEER 04 Nov 2019  
       
       
 
What are your hobbies ? SPORTS , PHOTOGRAPHY , MUSIC , TRAVELLING
What are your strengths ? WELL ORGANISED, PUNCTUAL , PUBLIC SPEAKING
What are your weaknesses ? BEING TOO HONEST
 
 
Declaration

I hereby declare that all the statements made above are true and correct.

Signature of Candidate

 

___________________

 

Date ________________

 
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