Application for Issuance of Certificate(Endorsement) For Service on Tankers

(Refer to instructions and Guidelines given overleaf for filling up application form) To, The Principal Officer, Mercantile Marine Department, Chennai. SUB: Application for Issuance of Certificate (Endorsement) for Service on Tankers. Particulars of Candidate: 1.Name: First Middle Last 2. Date of Birth: DD MM YY

(in block Letter) 3) (a) C.D.C No :

Dateof Issue : Dateof Issue :

Place of Issue:

3)(b) INDos No :I

4) Certificate of Competency / Service Grade: No:

5) Medical Certificate: [ (Format as per ILO Convention)( Photocopy to be attached)] 6) Modular Courses Done: (Photocopy to be attached) Yes a. Fire Prevention and Fire Fighting ( Basic): b. Advanced Fire Fighting: C.Oil / Chemical / Gas* Tanker Familliarisation / Safety* Course: d. Specialised Training Programme on Oil / Chemical / Liquid Gas Tankers e. Liquid Cargo Handling Simulator Course (2 Days): f. Liquid Cargo Handling Simulator Coure (5 days):
* Delete as appropriate

No

7) Record of Pre Sea Training: (On type of Tankers for which endorsement in sought) Rank Served Total Time Served Certificate of Competency held

Vessels Particulars Name Type Port of Registry

Duration From To

8) Issuance of Certificate (Endorsement) of Service on Tankers requested as follows:

Type of Tanker Oil / Chemical / Liquid Gas * Tanker

Level# Level 1 / Level 2 **

Number:

Date of Issue

Place of Issue:

*Delete as appropriate
** Level1 = Qualified to be assigned specific duties and responsibilities related to cargo equipment ** Level2 = Qualified to hold immediate responsibility for loading,

I hereby declare that the particulars given above are correct and true to the best of my knowledge and belief. I have read the instructions given overleaf. Date:..Place Signature of applicant:.. (FOR OFFICIAL USE)

Receipt No: Fees Paid Rs:

Date: Office Assistant.

I have scrutinized above application in line with applicable guidelines. Candidate is eligible for Issuance of Certificate & (Endorsement) for service on Tankers as requested and may be issued. Endorsement No.: .. Signature Dated: Name of Officer. In Capacity ofLevel 1 / Level 2 Designation.. Type of Tanker Oil / Chemical / Liquefied Gas

Instructions and Guidelines

Note: 1. Application should be accompanied by original certificates and attested photocopies of following: (a) C.D.C./ INDos . Cert. / Passport (b) Certificate of Competency (For Officers) (c) Medical Certificate (d) Fire prevention and Fire Fighting (e) Advance Fire Fighting (f) Oil / Chemicals / Gas Tanker Familiarization Course (g) Specialised training Programme on Oil / Chemical / Liquid Gas Tankers (h) Liquid Cargo Handling Simulator Course 2 1/2 days (Optional Level) (i) Liguid Cargo Handling Simulator Course 5 days (Management Level) (j) Previous Dangerous Cargo Endorsement 2. Applicant should apply and collect certificate in person. 3. Appplication for Certificate (Endorsement) for service on Tankers for each type of Tankers should be applied separately 4. Medical certificate submitted should be issued within last 6 months prior to application date. 5 Modular courses required in 6 are as per following regulations: Training Level 1 Basic STCW 95 Reg. V/1 Para 1 Officers Operational Level
- Appropriate Certificate of Competency

Ratings Support Level

W/K Certificate. Advanced Fire Fighting Course - Fire Prevention and Fire Fighting (STCW code A-VI/3) (STCW Code A-VI/1-2) Tanker Familiarization Course ( Oil / Chemical / Liqufied Gas Tanker ) AND - Liquid Cargo handling simulator Course of 2-1/2 days (For Deck Officers on Tankers Onlyl

OR
- 3 months supervised shipboard service ( Oil / Chemical / Liquid Gas Tanker)

Level 2 Advanced STCW 95 Reg. V/1 Para 2

Management Level Appropriate certificate of Competency Advanced Fire Fighting Course ( STCW Code A-VI/3) Oil Tanker Operations OR Chemical Tanker Operations OR Liquified Gas Tanker Operation 3 months experience appropriate to duties on the type of tanker Advanced Liquid Cargo handling simulator Course of 5 days { For Deck Officers on Tankers Only)

Revalidation of Tanker Endorsement STCW 95 Reg. 1/11 para. 1

At least 3 months experience during last five years on appropriate type of tanker OR Under take appropriate refresher training

7. Record of Sea-Service 7(a) Record of sea-Service required is to be filled starting from latest first. 7(b) For Foreign flag vessels the Sea-Service has to be duly verified by the local representative (in India) of the Owner / Manager on letter head. (FOSMA/MASSA Member) OR Documents to be endorsed by Indian Consulate Abroad or Appropriate Consulate in Indian. 8. Candidate should ensure that Form is correctly filled up and all required documents are attached, otherwise Candidate will be declared inelligible for certification. 9. Candidates are reminded that Fees once paid cannot be re-imbursed or transferred, hence ensure prior that he is meeting the requirements applicable. 10. Two recent passport size colour photographs are to be submitted along with the application form. 11. Payment of fees, to be made by Bank Demand Draft in favour of P.O. MMD Chennai. Fees payable as follows: DC Endorsement as per 1995 Convention: Rs. 1,000/12. Any person who makes a false representation or knowingly gives a false information is liable for punishment for Cheating under Sections 182 and 420 of the Indian Penal Code. payment