You are on page 1of 10

Quality Assurance into the 21st

Century and beyond


Personnel Form
TSM Form
No. 070

☐ Application Date of Application: _18/03/19_______________________


☐ Nomination
Position Applied: _____C/E_____________________
☐ Promotion
☐ Amendments Readiness to Join: ______immediate___________________

A. Personal

Family Name Given Name Middle Name Gender

Manokaran vijayakeerthy M
Birth Date Social Security / Tax Ref
Place of Birth Nationality National Reg. No.
(DDMMYY) Number

03/06/1983 vellore Indian

Address Contact Email

9944489994
3/1,6th street gopalakrishna nagar ,vellore-6,Tamil nadu vijayakeerthy@yahoo.co.in

Passport No. Place of Issue Issued Date Expiry Date Civil Status

Z2682702 chennai 10-10-2013 10-10-2023

US Visa No. Place of Issue Issued Date Expiry Date Religion

J3490143 Chennai 12-5-15 12-5-20 Hindu

Schengen Visa No. Place of Issue Issued Date Expiry Date Nearest Int’l Airport

no chennai

B. Next of Kin

Family Name Given Name Middle Name Relationship

Chinnasamay Manokaran Father

Address Contact Details

Home:0416-2240113
3/1,6th street gopalakrishna nagar ,vellore-6,Tamil Nadu
Cell:9944055106

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 1 of 10
TSM Form No. 070
Personnel Form

C. National Certification

Graduated From Highest Qualification Year of Graduation


Mohamed sathak engineering B.E Marine 2004
college
Discharge Book No. Issued Date Expiry Date

CH51153 18-11-2004 18-11-2024

National Certificate No. Issued Date Expiry Date Issuing Country

95W8095 12-FEB-2015 10-11-2021 INDIA

D. Bio Data

Height (cm) Weight (kg) Color of Eyes Color of Hair

173 81 black Black

Boiler Suit Size Safety Shoe Size

XL 9

E. Certificates and Qualifications

Issued Expiry
Documents Held STCW’95 Flag State Number

Foreign Certificate of STCW II – Deck


Competency (s)
STCW III -
Engine

STCW IV – Radio

Ratings Watch keeping Cert - STCW A-II/4


Deck

Ratings Watch keeping Cert - STCW A-II/4


Engine

Basic Safety Training STCW A-VI / 1


7-nov-17 7-nov-22
1. Personal Survival RPSCRB/B43
Technique 6/10

2. Fire Prevention and Fire RAFF/B388/1 08-Nov-17 07-Nov-22


0
Fighting
MFA/B391/02 06-June-06
3. Elementary First Aid
PSSR/B481/0 10-Mar-04
4. Personal Safety and 8
Social Responsibility

Proficiency in Survival Craft and STCW A-VI / 2 RPSCRB/B43 7-nov-17 7-nov-22


Rescue Boats 6/10

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 2 of 10
TSM Form No. 070
Personnel Form

Ship Handling & Manoeuvring STCW A-II / 2

Bridge Team Management or STCW A-II / 1


Bridge Resource Management (IMO Model 1.22)

Generic ECDIS STCW A-II / 1


(IMO Model 1.27)

Engine Room Simulator or STCW A-III / 1&2 ERS/B058/1 12-11-13


Engine Room Resource (IMO Model 2.07) 3
SSO/B164/14
STSDSD or SSO STCW A-VI / 6 or 13-Apr-
5 2013

Tanker Specific Requirements

Basic Tanker Training STCW A-V/1-1.1


(Oil/Chem/Gas) & 2.1

Advanced Tanker Training (Oil) STCW A-V/1-1.2 TASCO/C 10-11-21


HE/786/
17

Advanced Tanker Training (Chem) STCW A-V/1-1.2 CHEMCT 10-11-


/CHE/78 2021
9/17

Advanced Tanker Training (Gas) STCW A-V/1-2.2 GASCO/B1 10-06-10


2/10

FRAMO experience Yes Centrifugal Pumps with Yes


Pump Room

Wartsila-Sulzer RT-flex No Man B&W ME experience No


experience

F. Other Qualifications / STCW’95 Courses

Certificate Name Certificate No. Date of Issue Date of Expiry

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 3 of 10
TSM Form No. 070
Personnel Form

G. Sea Service Record (Note: Sea service should be listed in chronological order with most recent assignment first and
should include details for the past 5 years as a minimum)
Engine Period
T (DD/M
y M/YY)
p
Vessel DWT / Length of Ship
Rank Vessel Name e

/ From To
K
W
C/E ALMYROS Bulk 56768 MAN B&W 31-07- 22-11- Dynocom
Carrier 6S60MC-C 18 18 3M25D

C/E SAUBAAGYA 5 Bulk 53505 MAN B&W 13-12- 18-04- VSHIPS


Carrier 6S50MC-C 17 18 4M06D
C/E BW BARLEY Bulk 83369 MITSUBISHI 03-Jan- 22- SYNERGY
Carrier MAN B&W 2017 June-17 05M20D
6S50MC-C
C/E OEL BENGAL Contain 14910 B&W 07-06- 22-09- OESM
er 5S50MC 16 16 03M04D
2/E HIGH Product 48711 MAN B&W 02- D`AMICO
PROSPRITY tanker 6S50MC-C FEB- SHIPS
29-oct-
2016 03M27D ISHIMA
2015
INDIA

2/E GLENDA Product 48711 MAN B&W D`AMICO


MELLANI tanker 6S50MC 04- 29-Jun- SHIPS
Feb- 2015 05M03D ISHIMA
2015 INDIA

2/E GLENDA Product 47162 MAN B&W 26-Jan- 5-Jun- D`AMICO


MELLANI tanker 6S50MC 2014 2014 SHIPS
0M26D ISHIMA
INDIA

2/E GLENDA Product 47238 MAN B&W 13- 8-Jan- D`AMICO


MELODY tanker 6S50MC Dec- 2014 SHIPS
2013 04M0D ISHIMA
INDIA

2/E ATLANTIC STAR Product 49999 MAN B&W 26-Aug- ANGLO


22-Jan-
tanker 6S60MC-C 2012 05M03D EASTERN
2013
2/E SAGA Bulk 46550 SULZER 14- ANGLO
15-Apr-
ENTERPRISES Carrier RTA Nov- 01M23D EASTERN
2012
2011
3/E SAGA Bulk 46550 SULZER 22- 14-Nov- ANGLO
ENTERPRISES Carrier RTA Sep- 2011 06M22D EASTERN
2011
3/E LPG ESHIPS Gas 7879 MAN B&W 28- 16- ANGLO
SHAMAL caarrier 5S50MC-C Jan- Aug- 6M02D EASTERN
2011 2011
3/E ATLANTIC ROSE Oil 49999 MAN B&W 19- 19-Nov- ANGLO
Chemic 6S50MC-C May- 2010 6M02D EASTERN
al 2010
4/E NEW VISION Oil 164251 MAN B&W 16-Jul- 12-Jan- VSHIPS
tanker 7S80MC-C 2008 2009 05M29D
4/E ANGELO DELLA Bulk 127774 B&W 17- 28-Apr- 05M13D VSHIPS
GATTA carrier 5S60MC-C Nov- 2008

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 4 of 10
TSM Form No. 070
Personnel Form

2007

4/E VLCC PREM Oil 250145 MAN B&W FLEET


28- 15-
PUTLI tanker 7S80MC-C MANAGE
May- Sep- 03M17D
MENT
2007 2007
5/E LANCY NAIK Oil 67170 SULZER 25-Jun- 30-Dec- SCI
KARAM SING tanker RTA 2005 2005 06M04D

H. Reference(s) from Previous Employment

No. Company Name of Contact Person Contact Details

11 Dynocom tanker Mr.Sathya narayanan 9444110562

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 5 of 10
TSM Form No. 070
Personnel Form

I. Cargo Experience Information Sheet

 For Tanker Vessels – refer to Annex 1


 For Dry Bulk Vessels – refer to Annex 2

I would like to apply for a position on below ship types based on my personal preference and
relevant experience (tick as applicable):

TANKERS
Ship
Ship size Tick if Tick if
Ship type Ship type size
(DWT) Applicable Applicable
(DWT)

Very Large Crude Carrier 160K+ ☐ Asphalt & Bitumen Carrier ALL ☐

AFRAMAX / SUEZMAX 80-160K ☐ Very Large Gas Carrier ALL ☐

Chemical Tanker
ALL ☐ LPG ALL ☐
(Hard Core Chemicals)

Chemical Tanker
ALL ☐ LNG ALL ☐
(Soft / Easy Chemicals)

Product Tanker ALL ☐ Ethylene Carrier ALL ☐

DRY BULK
Ship
Ship size Tick if Tick if
Ship type Ship type size
(DWT) Applicable Applicable
(DWT)

Very Large Ore Carrier >210 K ☐ Handysize + Handymax 40-50K ☐

Cape Size 130-200K ☐ Log Carrier ALL ☐

Panamax 80-130K ☐ Ice Class ALL ☐

Kamsamax + Supramax 50-80K ☐ Container Vessels ALL ☐

J. Declaration and Signature

I hereby certify that the information given above are true and correct to the best of my knowledge and belief
and that I have not withheld any information that would affect my application unfavourably.
Any false declaration I supplied herein may constitute ground for disqualification and non-acceptance to the
company and can be further subjected to applicable penalties in accordance to existing laws governing the
recruitment and employment of overseas seafarers.

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 6 of 10
TSM Form No. 070
Personnel Form

Signature of Applicant: Date:

Annex 1:
CARGO EXPERIENCE INFORMATION SHEET – TANKERS
Instruction to Applicant: Please tick appropriate box for cargoes that you have been carried before.

OIL / DPP YES


(Note: Experience with any 1 of the listed cargoes NO
is required for oil tanker assignment) As Rating As Jr Officer As Sr Officer
CRUDE OIL
FUEL OIL
CARBON BLACK

ASPHALT YES
(Note: Experience with any 1 of the listed cargoes NO
is required for asphalt tanker assignment) As Rating As Jr Officer As Sr Officer
ASPHALT
BITUMEN
COAL TAR
RESIDUAL OIL

CLEAN PETROLEUM PRODUCTS (CPP) YES


(Note: Experience with any 2 of the listed cargoes NO
is required for product (CPP) tanker assignment) As Rating As Jr Officer As Sr Officer
KEROSENE GTL
CONDENSATES
GASOLINE
GASOIL
JET A-1
AVGAS
DIESEL OIL
LUB OIL
AVIATION ALKYLATES
DISTILLATES

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 7 of 10
TSM Form No. 070
Personnel Form

SOFT CHEMICALS YES


(Note: Experience with any 2 of the listed cargoes NO
is required for soft chem tanker assignment) As Rating As Jr Officer As Sr Officer
VEGETABLE OIL
SOYA BEAN OIL
FAME
TALLOW
ETHYLENE DICHLORIDE (EDC)
STYRENE MONOMER
BENZENE
XYLENE
TOLUENE
ACIDS
SODIUM HYDROXIDE SOLUTION
UREA AMMONIUM NITRATE (UAN)

HARD CHEMICALS YES


(Note: Experience with any 1 of the listed cargoes NO
is required for hard chem tanker assignment) As Rating As Jr Officer As Sr Officer
MDI
TDI
PHENOL
PROPYLENE OXIDE / ISOPRENE
ACRYLATES
HEXAMETHYLENE DIAMINE (HMD)
CUMENE
LATEX
ACRYLONITRILE (ACN)
METHYL ETHYLENE GLYCOL (MEG) FIBRE
GRADE (0.5 PPM CHLORIDES)

GAS YES
(Note: Experience with any 2 of the listed cargoes NO
is required for gas tanker assignment) As Rating As Jr Officer As Sr Officer
AMMONIA, ANHYDROUS

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 8 of 10
TSM Form No. 070
Personnel Form

BUTADIENE
BUTANE
BUTANE-PROPANE MIXTURES
BUTYLENES
ETHANE
ETHYLENE
MIXED C4
PENTANES
PENTENE
PROPANE
PROPYLENE
PROPYLENE OXIDE
VINYL CHLORIDE

OTHER INFORMATION /
NO YES COMMENTS
AREAS OF KNOWLEDGE
CRUDE OIL WASHING
DEEP WELL PUMP EXPERIENCE
SPECIALISED FRAMO COURSE
TANK COATING – PHENOLIC EPOXY
TANK COATING – EPOXY
TANK COATING – ZINC PAINT
TANK COATING – STAINLESS STEEL
TANK COATING – MARINELINE
ANY OTHER RELEVANT INFORMATION THAT YOU WOULD LIKE TO INFORM US ABOUT:

Annex 2:
CARGO EXPERIENCE INFORMATION SHEET – DRY BULK
Instruction to Applicant: Please tick appropriate box for cargoes that you have been carried before.

YES
DRY BULK NO
As Rating As Jr Officer As Sr Officer
GRAIN & AGRICULTURAL PRODUCTS yes
COAL yes
ORE yes
STEEL & STEEL PRODUCTS yes
TIMBER

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 9 of 10
TSM Form No. 070
Personnel Form

LOGS
REEFERS
yes
(Container Vessels Only)
IMDG
yes
(Container Vessels Only)
OTHERS
(please specify below):

OTHER INFORMATION /
NO YES COMMENTS
AREAS OF KNOWLEDGE
GEARED VESSEL EXPERIENCE
IHI, MITSUBISHI
(if yes, please specify what kind of cranes)
TYPES OF HATCH COVERS
(please specify)

ANY OTHER RELEVANT INFORMATION THAT YOU WOULD LIKE TO INFORM US ABOUT:

CONTROLLED Revision: 15 April 2018


Approved by DPA/DMR
Page 10 of 10

You might also like