Quality Assurance into the
21st Century and beyond
Personnel Form
TSM Form
No. 070
☐
Application
☐ Date of Application:
Nomination ___________30/03/2024_____________________
☐ Promotion Position Applied: ABLE SEANAN________________
Readiness to Join: APRIL 2024________________
☐
Amendment
s
A. Personal
Family Name Given Name Middle Name Gender
UDOH FRIDAY EBONG ☐ M ☐ F
Birth Date Place of Social Security / Tax Ref
Nationality National Reg. No.
(DDMMYY) Birth Number
AKWA
11/03/1983 NIGERIA NA NA
IBOM
Address Contact Email
Home:
NO. IKOT EBIEYEM ROAD, IKOT EKPENE, [email protected]
AKWA IBOM STATE m
Cell: 09013765533
Place of
Passport No. Issued Date Expiry Date Civil Status
Issue
A1185811 NIGERIA 17/05/2021 16/05/2026 NA
Place of
US Visa No. Issued Date Expiry Date Religion
Issue
NA
Schengen Visa Place of
Issued Date Expiry Date Nearest Int’l Airport
No. Issue
B. Next of Kin
Family Name Given Name Middle Name Relationship
UDOH EZEKIEL EBONG BROTHER
Address Contact Details
Home:08037830846
UMOBELLE 4, OYIBO RIVERS STATE
Cell:
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TSM Form No. 070
Personnel Form
C. National Certification
Graduated From Highest Qualification Year of Graduation
Discharge Book No. Issued Date Expiry Date
NIG-026182 04/03/2010
National Certificate No. Issued Date Expiry Date Issuing Country
D. Bio Data
Height (cm) Weight (kg) Color of Eyes Color of Hair
1.72M 72 WHITE BLACK
Boiler Suit Size Safety Shoe Size
XLARGE 43
E. Certificates and Qualifications
Flag Issued Expiry
Documents Held STCW’95 Number
State (DDMMYY) (DDMMYY)
Foreign Certificate of STCW II –
Competency (s) Deck
STCW III -
Engine
STCW IV –
Radio
Ratings Watch keeping Cert - STCW A-II/4 NRAT. 27/09/22
Deck NAV.
2535
Ratings Watch keeping Cert - STCW A-II/4
Engine
Basic Safety Training STCW A- 011400 23/02/2021 22/02/2026
VI / 1 6
1. Personal
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TSM Form No. 070
Personnel Form
Survival Technique
2. Fire Prevention 23/02/2021 22/02/2026
and Fire Fighting
011400
3. Elementary First 6
23/02/2021 22/02/2026
Aid
23/02/2021 22/02/2026
4. Personal Safety
011400
and Social
6
Responsibility
011400
6
Proficiency in Survival Craft STCW A- 135894 19/02/2021 18/02/2026
and Rescue Boats VI / 2
Proficiency in Fast Rescue STCW A-
Boats VI / 2-2
Ship Handling & STCW A-II /
Manoeuvring 2
Bridge Team Management or STCW A-II /
Bridge Resource 1 (IMO
Management Model 1.22)
Generic ECDIS STCW A-II /
1 (IMO
Model 1.27)
Engine Room Simulator or STCW A-III /
Engine Room Resource 1&2 (IMO
Model 2.07)
STSDSD or SSO STCW A-
VI / 6 or 5
Tanker Specific
Requirements
Basic Tanker Training STCW A-
(Oil/Chem/Gas) V/1-1.1 &
2.1
Advanced Tanker Training STCW A-
(Oil) V/1-1.2
Advanced Tanker Training STCW A-
(Chem) V/1-1.2
Advanced Tanker Training STCW A-
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TSM Form No. 070
Personnel Form
(Gas) V/1-2.2
FRAMO experience Yes ☐ No ☐ Centrifugal Pumps Yes ☐ No ☐
with Pump Room
Wartsila-Sulzer RT-flex Yes ☐ No ☐ Man B&W ME-B/C Yes ☐ No ☐
experience experience
(electronic)
F. Other Qualifications / STCW’95 Courses
Certificate Name Certificate No. Date of Issue Date of Expiry
EFFICIENT DECK HAND 0000586/ 18/07/2012
JINSR/ABH/6/0586/2012
ISPS 05974/CMOSC/SAT/ 10/12/2015
12/15
RIGGING & SLINGING 220032022 13/03/2023 12/03/2026
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
Type / (DD/MM/YY)
KW
D Length Ship
(indicat
WT of Owner
Vessel e full
Rank Vessel Type / Time /
Name engine
TE Onboa Manag
make/ty From To
U rd er
pe for
enginee
rs)
AB/ CONSTRUC 3574 SAPU
2
RIGGE TION 05/01/2 RA
2/11/23 MONT
R 024 ENER
HS
GY
SAPURA SAPU
AB/
3500 DP3/PIPE 19/07/2 16/09/2 RA
RIGGE 40845 2
LAY 023 023 ENER
R
GY
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TSM Form No. 070
Personnel Form
MV
BRITA
PRINCE OIL 12/06/2 18/01/2
AB 576 6 NNIA-
EDWAR SERVICING 022 023
U
D
DSV 16/08/2 08/12/2 PETR
AB DSV/MPSV 4768 4
VINNICE 020 020 OLOG
DSV 04/02/2 30/04/2 PETR
AB DSV/MPSV 4768 2
VINNICE 020 020 OLOG
DSV 16/10/2 14/12/2 PETR
AB DSV/MPSV 4768 2
VINNICE 019 019 OLOG
MV
MILAHA CONSTRCTI 30/05/2 09/08/2 MILAH
AB 7945 2
EXPLOR ON 019 019 A
ER
MV
SALVI
SALVIN 30/04/2 04/09/2
AB MPSV 6464 2 N FAR
PRINCE 016 016
EAST
SS
NPDL CS
03/02/2 06/04/2
AB RANDE PSV 3542 2 OFFS
016 016
EP HORE
SPSL
ADAM
VICTORI
29/12/2 02/03/2 AC
AB A PSV 718 2
011 012 MARIN
SERVIC
E
E
AB SPSL AHTS 804 ADAM
BONNY 25/08/2 26/11/2 AC
3
SERVIC 011 011 MARI
E NE
AB SPSL PSV 744 25/04/2
ADAM
NORTH 011
21/07/2 AC
ROP 3
011 MARI
SERVIC
NE
E
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TSM Form No. 070
Personnel Form
For Offshore applicants only:
Anchor Handling operations during contract? ☐ Yes (If yes, how many hours / days _____) ☐ No
What depth? ___________ Anchor type? ______________ Location & name of rig?_____________
Towing during contract? ☐ Yes ☐ No. If yes, name of barge towed ________________________
From where to where? _________________ Tow Length? _________ Charterer? _______________
Boat handling experience? ___________________________________________________________
H. Reference(s) from Previous Employment
No. Company Name of Contact Person Contact Details
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)
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TSM Form No. 070
Personnel Form
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 ☐
OFFSHORE
Propulsion Type Any Other Tick if
Ship type DP Class
(CPP / Azimuths) Limiting Factors Applicable
☐
Anchor Handling Tug Supply
☐
Platform Supply Vessel
☐
Offshore Construction Vessel
Seismic (Mother Vessel) ☐
☐
Seismic (Chaser Vessel)
☐
Offshore Support Vessel
Accommodation Vessel ☐
☐
Dive Support Vessel
☐
Other (Specify):
J. Declaration and Signature
1. 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.
2. 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.
3. I give consent to the Company for holding and processing all my personal data as
disclosed in this Form for the purposes of (i) To keep me informed about any upcoming
vacancy (Note: you can unsubscribe from any time), (ii) To process my application, (iii) To
use my data for processing my Payment, as applicable, and (iv)To share my data with
such third party who act for and on behalf of the Company or in connection with the
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TSM Form No. 070
Personnel Form
business of the Company for further processing in accordance with the purposes for which
the data was originally collected.
[IMPORTANT NOTE: Please do note that you have the right to withhold your consent. You can
find out more about how we use your data from our “Public Privacy Policy” which is available from
our website at <https://www.thome.com.sg/wp-content/uploads/2018/11/Thome-Group-Public-
Privacy-Policy.pdf> or from the Company representative. You can also withdraw or change your
consent at any time by contacting the local manning office / agent or Company representative.]
Please note that all processing of your personal data will cease once you have withdrawn consent,
other than where this is required by law, but this will not affect any personal data that has already
been processed prior to this point.]
Signature of
Date: 30/03/2024
Applicant:
Annex 1:
Cargo experience information sheet – Tankers
Instruction to applicant: Please tick appropriate box for cargoes that you have been carried before.
Yes
Oil / DPP
(Note: experience with any 1 of the listed cargoes is required for No As
As Senior
oil tanker assignment) As rating Junior
Officer
Officer
Crude oil
Fuel oil
Carbon black
Yes
Asphalt
(Note: experience with any 1 of the listed cargoes is required for No As
As Senior
asphalt tanker assignment) As rating Junior
Officer
Officer
Asphalt
Bitumen
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TSM Form No. 070
Personnel Form
Coal tar
Residual oil
Yes
Clean Petroleum Products (CPP)
(Note: experience with any 2 of the listed cargoes is required for No As
As Senior
product (CPP) tanker assignment) As rating Junior
Officer
Officer
Kerosene GML
Condensates
Gasoline
Gasoil
Jet a-1
Avgas
Diesel oil
Lub oil
Aviation Alkylates
Distillates
Yes
Soft chemicals
(Note: experience with any 2 of the listed cargoes is required for No As
As As Senior
soft chemical tanker assignment) Junior
Rating Officer
Officer
Vegetable oil
Soya bean oil
Fame
Tallow
Ethylene Dichloride (EDC)
Styrene Monomer
Benzene
Xylene
Toluene
Acids
Sodium hydroxide solution
Urea Ammonium Nitrate (UAN)
Yes
Hard chemicals
(Note: experience with any 1 of the listed cargoes is required for No As
As As Senior
hard chem tanker assignment) Junior
Rating Officer
Officer
MDI
TDI
Phenol
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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 No As Junior As Senior
cargoes is required for gas tanker assignment) As Rating
Officer Officer
Ammonia, Anhydrous
Butadiene
Butane
Butane - propane mixtures
Butylenes
Ethane
Ethylene
Mixed c4
Pentanes
Pentene
Propane
Propylene
Propylene Oxide
Vinyl Chloride
Other information / Areas of knowledge No Yes Comments
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:
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TSM Form No. 070
Personnel Form
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 Junior As Senior
As rating
Officer Officer
Grain & agricultural products
Coal
Ore
Steel & steel products
Timber
Logs
Reefers (container vessels only)
IMDG (container vessels only)
Others (please specify below):
Other information / Areas of knowledge No Yes Comments
Geared vessel experience
(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:
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