Elegant Marine Services Private Limited

(Agents of Fleet Management Ltd.)

Our Principal’s Website: www.fleetship.com,
RPSL License No: RPSL- MUM- 172
DOI: 29/09/2015 DOE: 28/09/2020
Application Form / Personnel Data Update Form
th
Post applied for: 4 ENGINEER Willing to accept lower Rank? Yes, No Available From: 05/03/2023

(A) PERSONAL PARTICULARS (AS IN PASSPORT)

First Name: BALAJI Middle Name Last Name/Surname: KUMAR

Nationality: INDIAN Date of Birth: 01-SEP-1998 Place of Birth: THIRUMANGALAM

Height Weight (In KGS): 68 Smoker / Nonsmoker Yellow Fever Union Membership
(InCMS): Blood Group: O+VE Veg. / Non - Veg. DOI DOE BATCH /LOT
170 No. YES NO
Boiler Suit Size: MED / LARGE / XL / XXL Shoe Size: 09 29/01/19

Permanent Address: NO.7, NETHAJI NAGAR, 1ST STREET, PORUR, Local Address: NO.7, NETHAJI NAGAR, 1ST
STREET, PORUR,

City: CHENNAI Tel.: City: CHENNAI Tel.:

Post Code: 600116 Mobile: 7401361549 Post Code: 600116 Mobile: 7401361549
E-mail: [email protected]

Document No. Date of Issue Place of Issue Date of Expiry

DD/ MM/ YY DD/ MM/ YY
Passport: Country R3746362 16/08/17 CHENNAI 15/08/27

Seaman’s Book (CDC): National MUM347571 10/12/18 MUMBAI 09/12/28

Seaman’s Book (CDC): Norwegian

Seaman’s Book (CDC): Liberian 1537384 06/08/20 VIRGINIA, USA 06/08/25

Seaman’s Book (CDC): Panamanian

Seaman’s Book (CDC): Marshall Island
Other (CDC):
Valid US Visa “C1/D” Yes / No Date of Expiry: 13/08/24 Passport ECNR: Yes / No
Australian Maritime Crew Visa Yes / No Date of Expiry:

Next of kin: NAGAJOTHI. K Relationship: MOTHER DOB: 18/06/1977

Alternate next of kin:
(in case of family joining) Relationship:

Address: NO.7, NETHAJI NAGAR, 1ST STREET, PORUR, CHENNAI - 600116

Tel.: 7401361549
....................Family Details....................
Relationship First Name Last Name DOB Passport No. Place Issued Valid until
Spouse
Child M / F
Child M / F
* Indicate Type of Valid Visas USA / CANADA / BRAZIL / UK / Others
Anniversary date:
* Please check if visas and a l l doc um ents a re v a l i d for the tenure on board, plus 6 months.

Page 1 of 9
FORM No.: Annex 11/OPM
REV. No.: 02 / 2019
Applicant Signature:

Page 2 of 9
FORM No.: Annex 11/OPM
REV. No.: 02 / 2019
(B) Education / Other Qualifications:
EDUCATIONAL QUALIFICATION
Result Grade (1st, 2nd,
10 + 2 / Degree Institution / University Year of Passing 3rd or A, B, C etc.)
10 + 2 HOLY ANGEL’S MAT. HR SEC SCHOOL 2015 B
PRE - SEA TRAINING / APPRENTICESHIP / MARINE ENGINEERING / NAUTICAL DEGREE OR DIPLOMA
Result Grade (1st, 2nd,
Pre - Sea Training Training Institution / Company Name From - To 3rd or A, B, C etc.)
B.E (MARINE ENGINEERING) AMET UNIVERSITY 2015-2019 B

CERTIFICATES OF COMPETENCY:
Highest Competency Certificate Held MEO CLASS IV
Date of Passing Examination 06/04/22
Issuing Authori t y Grade Certificate No. DOI Place Issued Valid until
National ( Country) MEO CLASS IV 95Z-35055 01/06/22 CHENNAI 05/04/27
Liberian
Panamanian
Marshall I s l an d
Norwegian
Hongkong
Others
GMDSS
GMDSS ( Endorsement)
LIST OF S.T.C.W. / OTHER COURSES DONE
Courses STCW 1995 STCW 2010 Date of Issue Date of Expiry
1) FPFF / Advanced Fire Fighting 4030196311210114 27/05/21 26/05/26
2) Elementary / Medical F i r s t A i d / 4030196411210146 02/06/21 01/06/26
Medicare
3) PSSR 11/B005/BST 04/08/18
4) Proficiency in Survival Craft & RB / PST 40301962112101212 21/05/21 20/05/26
5) STSDSD 11/B258/STSDSD 07/08/18
6) CTFC / CHEMCO 4030195113220016 26/05/22
7) GTFC / GASCO 403019075190094 20/07/19
8) OTFC / TASCO 2010015112220237 16/06/22
9) LCHS (Management / Operational)
10) Ship Maneuvering Simulator Course
11) Radar Observer Course / ARPA
12) Radar Simulator Course / RANSCO
13) BTM / BRM
14) Ship Security Officer Course
15) NIS Familiarization Course
16) C.O.C. Revalidation Course
17) INDOS No. (Mandatory Requirement) 16EL0262 19/01/16
18) STCW 2010 Refresher Courses
19) High Voltage Course 40100117119043 19/02/19
20) Seafarers Identify Documents (SID) C31030516 12/07/19 11/07/29
21) Others (Specify)
Dangerous Cargo Certification:
1. Endorsement on NATIONAL Certificate Level Number DOI Place Issued Valid Until
Petroleum ADVANCE DCE02CHN22005 21/06/22 CHENNAI 20/06/27
491
Liquefied Gas BASIC COPDGSGAS1908 25/09/19 MUMBAI
45
Liquid Chemicals ADVANCE DCE02CHN22005 21/06/22 CHENNAI 20/06/27
492
2. Other Endorsements

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FORM No.: Annex 11/OPM
REV. No.: 02 / 2019
Applicant’s Signature

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FORM No.: Annex 11/OPM
REV. No.: 02 / 2019
(C) SEA SERVICE: (Start from Last Vessel Served)
Flag of Type of Engine make & model & BHP/KW (For Engineers) DWT (D) From To Total
Name of the Company Name of the Vessel Rank
Vessel Vessel Cargoes Carried (For Deck Officers) GRT (G) dd/mm/yy dd/mm/yy M/D
Non-Fleet Management Vessels
GOODWOOD SHIP M.T DHT JAGUAR HONG VLCC MAN B&W & G80ME-C9 & 32720.9 BHP 154180 (G) ENGINE 03/10/19 25/06/20 9M
MANAGEMENT KONG CADET
GOODWOOD SHIP M.T TAURUS LIBERIA OIL/ MAN B&W & 6S50MC-C & 12712.8 BHP 29734 (G) JUNIOR 24/07/20 30/04/21 9M
MANAGEMENT CHEM ENGINEE
R
GOODWOOD SHIP M.T EAGLE BAY SINGAP OIL/ MAN B&W & 6S50MC-C & 12712.8 BHP 29266 (G) ASST.4TH 05/07/22 06/02/23 7M
MANAGEMENT ORE CHEM ENGINEE
R

Remarks:

Sea Service with Fleet Management Vessels

Applicant’s Signature

FORM No.: Annex 11/OPM

REV. No.: 02 / 2019
(D) Experience Matrix of Engineer Officer
Please mark ‘Y’ against your rank in the cell, if that experience is applicable to you
S.No. Crane Make C/E 2/E 3/E 4/E E/O Any Breakdown experience / Remarks
Experience on Deck / Cargo Machinery
1 Haaglund
2 Liebherr
3 IHI
4 Mitsubishi
5 NMF
6 Atlas
7 BLM
8 MacGregor
9 Any Other Y
Grab Make
1 SMAG Peiner
2 ORTS
Experience on Reefer Machinery / Reefer Container
1 Direct System
2 Indirect S y s t e m
3 Carrier Trans i c o l d
4 Thermoking
5 Daikin
6 Mistubishi
7 Any Other
Experience on Oil / Chemical / Gas Tankers
1 Framo Pum p s Y
2 Centrilina P u m p s
3 Steam Turbines
4 Any Other
Experience on Propulsion System / Maneuvering System
1 CPP
2 Bow/Stern thrus ter
3 Twin Screw
4 NOR Control
5 Kongsberg
6 Any Other Y
Experience on Auxiliary Engines
1 Yanmar
2 Daihatsu
3 Sulzer
4 MAN B&W Y
5 Cummins
6 Caterpillar
7 Pielstik
8 Volvo Penta
9 Any Other

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 S.No. Crane Make C/E 2/E 3/E 4/E E/O Any B reakdow n experience / Remarks
Experience of major overhaul / breakdown
1 Drydock Y
2 M/E Turbocharger
3 M/E Governer
4 M/E Cyl. Liner Y
5 Thrust Block
6 A/E Crankshaft
7 Alternator overhaul
8 Steering Gear Y
9 Any Other
Experience in Disaster Management
1 Grounding
2 Collision
3 Oil Spill
4 Crank Case Explosion
5 Scavenge Fire
6 Engine Room Fire
7 Cargo Fire
8 Abandon Ship
9 Steering Failure
10 Any Other
Experience in PMS
1 AMOS
2 TM Master

Applicant’s Signature

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(E) Experience Matrix of Deck Officer
Please mark ‘Y’ against your rank in the cell, if that experience is applicable to you
S.No. Description M CO 2O 3O Cdt Any Breakdown or incident experience /
Remarks
Have you sailed in the following areas?
1 Indian Ocean
2 Pacific Ocean
3 North Atlantic Ocean
4 South Atlantic Ocean
5 South China Sea
6 Australian W a t e r s
7 Mediterranean Sea
8 Black Sea
9 English Channel / North Sea
10 Singapore St rai t s
11 Panama Canal
12 Suez Canal
13 Kiel Canal
14 Great Lakes
15
16
17
Chemical / Product Tanker Tank Cleaning experience
1 Cleaned tanks after carriage of veg. oil?
2 Cleaned tanks for Methanol carriage?
3 Cleaned tanks MEG or similar cargoes?
4 Cleaned tanks for Veg Oil carriage?
5 Cleaned tanks for Jet Fuel?
6 Changed from dirty to clean products?

Gas Tanker Experience

1 Fully Refrigerated vessel
2 Fully pressurized vessel
3 Partially refrigerated vessel

Oil / Product / Chemical T a n k e r E x p e r i e n c e

1 Inert Gas vessel
2 Crude Oil Washing
3 Inert Gas purging
4 Cleaning crude oil tanks for hot work
5 Framo Pumps operation
6 Cargo Heating
7 Framo Pump damage
8 Over / Under pressurization of tanks
9 Cargo c o n t a m i n a t i o n

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 S.No. Description M CO 2O 3O Cdt Any Breakdown or incident experience/
Remarks
Bulk Carrier Experience
1 Hose test for hatch covers
2 Bilge valve testing
3 Ballasting of cargo hold
4 Disposal of cargo residues
5 Draft survey cargo calculations
6 Over / Under pressurization of Holds
7 Cleaned Holds for Grain carriage?
8 Cleaned Holds for Fertilizer carriage?

Experience of major overhaul / breakdown

1 Drydock
2 Windlass damage / Loss of Anchor
3 Steering Gear failure

Experience of Special circumstances & Disaster Management

1 Grounding
2 Collision
3 Oil Spill
4 Crank Case Explosion
5 Scavenge Fire
6 Engine Room Fire
7 Cargo Fire
8 Abandon Ship
9 Steering Failure
10 Freezing Weather
11 Heavy weather / TRS
12 Fog / Restricted visibility

Experience in PMS
1 AMOS
2 TM Master

Applicant’s Signature

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 (F) GENERAL:
(1) Have you ever been denied a foreign visa or been deported from any country? Yes / No
If yes, state which country and reason (if known):
(2) Have you been the subject of a court of enquiry or involved in a maritime accident? Yes / No
If yes, please attach details
(3) Have you ever signed off a ship due to medical reason within last 3 years? Yes / No
If yes, please provide following details:

Name of vessel Date of occurrence Place of occurrence

Reason for sign off:

(4) Have you ever been involved in any criminal activity or have pending criminal case? Yes / No
If yes, please provide details.

(5) Have you ever been involved in any navigational incidents in last 24 months? Yes / No
If yes, please provide details.

(6) Are you Currently under Medical Treatment or Taking Medication for Existing conditions? Yes / No
If Yes, please provide details
Comments on above

(D) Last drawn salary in USD: 2230

(E) References
Please give referees from two recent employers who we may contact for references
Reference 1 Reference 2
Name of Company GOODWOOD SHIP MANAGEMENT
Name of Person to contact
Address #02-34/36, TeleTech Park, 20 Science
Park Rd, Singapore 117674
Country SINGAPORE
Telephone

I Do hereby declare that all information furnished is true to best of my knowledge and belief.

Received acknowledgement of Application form

Date: 17/02/23 Rank: 4TH ENGINEER Applicant’s Signature

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(G) FOR OFFICE USE ONLY

STAGE II (Checked by: Personnel Officer) Name: Sign

Documentation c h e c k s
a) Copies of all STCW certificates received? Yes / No
b) Copy of all valid Certificates of Competency including Endorsements received? Yes / No
c) Copy of National or Main Certificate of Competency verification certificate received? Yes / No
d) Copies of Passport including all valid visas received? Yes / No
e) Copies of Seaman’s Book including all pages containing sea service received? Yes / No
f) Copies of Vaccination Book received? Yes / No

Comments regarding non-receipts:

STAGE III (Assessed By: Marine / Tech. Superintendent / Manager / Deputy General Manager / General Manager)

Name: Sign

Comments:

Regd. Office: Elegant Marine Services Private Limited: 401/A, Elegant Business Park, Off Andheri
Kurla Road, Near Kohinoor Continental Hotel, Andheri (E), Mumbai - 400 059. India

Corporate Office: Elegant Marine Services Private Limited: 601/A, Elegant Business Park, Off Andheri
Kurla Road, Near Kohinoor Continental Hotel, Andheri (E), Mumbai - 400 059 India
Tel: (+91 22) 3090 6100 Fax: (+91 22) 3090 6200
e e

E-mail [email protected]

Liaison Offices: GURGAON: Tel. (0124) 4690400 / KOLKATA: Tel: (033) 40566100 /
KOCHI: Tel: (0484) 4063666 / CHENNAI: Tel. (044) 22504730 /
VIZAG: Tel (0891) 2749775 / PATNA: Tel. (0612) 2206788
LUCKNOW: Tel. (0522) 4024685 / CHANDIGARH: Tel. (0172) 4751200

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