TSM 070 Form

Quality Assurance into the 21st
Century and beyond
Personnel Form
TSM Form
No. 070
THOME
SHIP MANAGEMENT PTE LTD
Application
Nomination
Promotion
Amendments
Date
27 May 2016
Position
CHIEF MATE
A. Personal
Family Name
Given Name
Middle Name
THAPLIYAL
SANJAY
Birth Date
(dd MM yy)
Place of Birth
Nationality
24 NOV 194
RUDRAPRAYA
G
INDIAN
Sex
X M
National Reg. No.
Religion
HINDU
Address
Contact No.
Email
FH 15/203 GTM FOREST & HILL OPP IIP GATE

HARIDWAR ROAD DEHRADUN
Passport No.
Place of Issue
Date of Issue
Expiry Date
Civil Status
L4493238
DEHRADUN
30/07/2013
29/07/2023
MARRIED
US Visa
Place of Issue
Date of Issue
Expiry Date
Nearest Airport
YES
NEW DELHI
24/07/2012
23/07/2017
DEHRADUN
Next of Kin
Family Name
Given Name
Middle Name
Relationship
THAPLIYAL
BHUWAN
CHAND
FATHER
Address
Tel/Cell/Fax
SAME AS ABOVE
+919412987866
B. National Certification
Graduated From
Highest Education
Year
SHOBHIT UNIVERSITY
B COM
2016
CONTROLLED
Revision: 01 Jan 2014

Approved by DPA/DMR
Page 1 of 8
TSM Form No. 070

Personnel Form
THOME
Seamans Book No.
Issued Date
Expiry Date
Medical Clinic
Expiry Date
MUM124582
27/06/2015
26/06/2025
DR KANWAR
06/10/2016
National Certificate No.
Issued Date
Expiry Date
Issuing Country
IFO 19415
23/09/2015
29/07/2015
INDIA
C. Certificates and Qualifications
Documents Held
STCW95
Flag
State
Number
Issued
(DDMMYY)
Expiry
(DDMMYY)
Foreign Documents
REG III - Engine
REG IV Radio
Tanker Qualification
REG V/1-2 Assistant
Advanced Oil
REG V/1-2 In Charge
Advanced Chem
Advanced Gas
General Tanker Fam.
COW/Inert
Familiarisation
Training/SSO
Basic Safety/PST
104/3895/0636
BPMA/PST/793/2003
FOS
MA
21/12/201
3
BPM
17/09/201
3
NAT
COM
14/04/201
1
NAT
COM
07/04/201
1
ARI
13/09/201
4
Advanced Safety Course

ARPA
ROC
RSC
NATCOM/ARPA/059/2011
NATCOM/ROC/063/2011
RA14122
Bridge Team Management
CONTROLLED

Approved by DPA/DMR
Page 2 of 8
TSM Form No. 070

Personnel Form
THOME
GMDSS/INMARSAT
D2791
21/03/201
1
20/03/202
1
GOC Certificate
MMD/DE
L/9276
03/08/201
5
02/08/202
0
Ratings Watchkeeping Cert

Ship
Handling
Manoeuvring
&
AMOS Windows / DOS

FRAMO experience
Yes
No
D. Sea Service Record
Rank
Vessel
Flag
IMO
Type
GRT
C/O
OCEAN
COLOSSUS
SGP
BULK
33183
2/O
WESTERN
OSLO
OSLO
BULK
31532
BULK
BHP
Period (DD/MM/YY)
Management
From
To
13/10/15
10/03/16
07/02/14
11/08/14
51201
23/12/12
20/06/13
FML
FML
FML
2/O
OCEAN
DIAMOND
2/O
STELLAR
CUPID
PAN
LOG/B
ULK
30146
28/07/12
31/10/12
FML
2/O
PACIFIC
PIONEER
HNG
BULK
38267
10/11/11
11/05/12
VRM
3/O
GLOBAL
TRIUMPH
MHL
BULK
38852
22/04/10
22/10/10
ASP
HNG
E. Information Sheet Chemical Tankers
Cargoes Carried: Tick Appropriate Box

DODECYLBENZENE (LAB)
HYDROGEN PEROXIDE
ACRYLONITRILE
SULPHURIC ACID
NITRIC ACID
PHENOL
EPICHLOROHYDRIN (ECH)
CONTROLLED

Approved by DPA/DMR
Page 3 of 8
TSM Form No. 070

Personnel Form
THOME
CAUSTIC SODA
HEXANE
XYLENE
MDI / DIPHENYLMETHANE DIISOCYANATE
TOLUENE
METHANOL
PALM OILS
VEGETABLE OILS
MOLASSES
ETHYLENE DICHLORIDE (EDC)
STYRENE MONOMER
BENZENE
VINYL ACETATE MONOMER (VAM)
IPA / NBA
METHYL ETHYELENE GLYCOL (MEG)
LUB ADDITIVES / LUBRIZOL
LUB OIL
SODIUM HYDROSULPHIDE
PHOSPHORIC ACID
PROPYLENE OXIDE / ETHYLENE OXIDE
LIQUID NYLON
CONDENSATE
PARAFFIN WAX
GASOLINE
GASOIL
CONTROLLED

Approved by DPA/DMR
Page 4 of 8
TSM Form No. 070

Personnel Form
THOME
JET A-1
NAFTA
HVGO
FUEL OIL
DIESEL OIL
RAFINERY SOYA BIN OIL
CRUDE SOYA BIN OIL
NITRATE SODIUM SOLUTION
OTHER INFORMATION / AREAS OF KNOWLEDGE: SCREW PUMPS
CENTRIFUGAL PUMPS
DEEP WELL PUMPS EXPERIENCE
SPECIALISED FRAMO COURSE
CLOSED LOADING / VECS.
CDI / CHEMICAL DITRIBUTION INSTITUTE
OIL COMPANY INSPECTION
USGC LETTER OF COMLIANCE
CARGO HEATING OIL/ STEAM/ DECK HTR.
TANK COATING TYPE Zn/ SS/ EPOXY
WALL WASH TESTING (HC/ CL)
PERMANGEMATE TESTING (PTT)
PASSIVATING STAINLESS STEEL TANKS
ISM / ISO
TRADE AREAS
CONTROLLED

Approved by DPA/DMR
Page 5 of 8
TSM Form No. 070

Personnel Form
THOME
N2 PADDING
CARGO COOLING SYSTEM
OPA 90 TRAINING
ANY OTHER RELEVANT INFORMATION YOU WOULD LIKE TO INFORM US ABOUT:
F. Other Qualifications / STCW95 Courses
Course
Certificate No.
Date of Issue / Expiry
EFA
BPMA/E/45/2003
27/09/2003
BPMA/PSSR/847/2003
24/09/2003
PSSR
AFF
CMET/AFF/271/2
287
PSCRB
MMTI/PSCRB/68
47/2011
MFA
NATCOM/MFA/04
6/2011
MEDICARE
CMETD/SMC/000
9/0016
RUTC
CMETD/RUTD/00
27/0094
30/04/2011
26/02/2011
21/04/2011
25/09/2014
17/06/2015
English Language: Excellent

G. Bio Data
Height
Weight
183
87
Colour of Eyes
Colour of Hair
BLACK
GREY
H. Allotment and Social
Seamans Social Security Number
Individual Tax Number
CONTROLLED

Approved by DPA/DMR
Page 6 of 8
TSM Form No. 070

Personnel Form
THOME
Allotee Family Name
Given Name
Relationship
Date of Birth
1.
Address
% Allotment
Bank/Branch
Account No.
Allotee Family Name
Given Name
Relationship
Date of Birth
2.
Address
% Allotment
Bank/Branch
Account No.
Allotee Family Name
Given Name
Relationship
Date of Birth
3.
Address
% Allotment
Bank/Branch
Account No.
I. Reference(s) from Previous Employment
No.
Company
Name of Contact Person
Tel/Fax
2.
3.
1.
J. Declaration and Signature
I hereby certify that the information given above are true and correct to the best of my knowledge and
belief. 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
CONTROLLED

Approved by DPA/DMR
Page 7 of 8
TSM Form No. 070

Personnel Form
THOME
the recruitment and employment of overseas seafarers.

Signature of Applicant
Date
K. Interview For Office Use Only
Interviewer
Date of Interview
Date Available
Recommended As
Date of
Contract
Comments
CONTROLLED

Approved by DPA/DMR
Page 8 of 8
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Quality Assurance into the 21st

Century and beyond

National Reg. No.

FH 15/203 GTM FOREST & HILL OPP IIP GATE

Revision: 01 Jan 2014

TSM Form No. 070

Seamans Book No.

National Certificate No.

C. Certificates and Qualifications

REG V/1-2 Assistant

REG V/1-2 In Charge

Advanced Safety Course

Bridge Team Management

Revision: 01 Jan 2014

TSM Form No. 070

Ratings Watchkeeping Cert

AMOS Windows / DOS

D. Sea Service Record

E. Information Sheet Chemical Tankers

Cargoes Carried: Tick Appropriate Box

Revision: 01 Jan 2014

TSM Form No. 070

Revision: 01 Jan 2014

TSM Form No. 070

Revision: 01 Jan 2014

TSM Form No. 070

F. Other Qualifications / STCW95 Courses

Date of Issue / Expiry

English Language: Excellent

H. Allotment and Social

Seamans Social Security Number

Individual Tax Number

Revision: 01 Jan 2014

TSM Form No. 070

Allotee Family Name

Allotee Family Name

Allotee Family Name

I. Reference(s) from Previous Employment

Name of Contact Person

J. Declaration and Signature

Revision: 01 Jan 2014

TSM Form No. 070

the recruitment and employment of overseas seafarers.

K. Interview For Office Use Only

Revision: 01 Jan 2014

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