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APLICATION FROM CREW

Position Applied : Engine Rating


Name : Hendra Weight : 53 kg
Rank : Weaper Seaman Height : 165 cm
Birth Place : Karawang Shoes size : 40
Date of Birth : Oktober 28th , 1989 Clothes size : M
Nationality : Indonesia Blood pressure :
Married : Married Blood type :
Religion : Islam Eye colour : Brown

Address : Jl. Tipar Cakung, Rt.05/ Rw.01 Sukapura


Cilincing, Jakarta Utara Mobile : 089999998979
Emergency Contact
1. Supriyadi Phone : 085719197456

Number Issued Date Expire Date Issued by


Passport
S/Book B 067257 May 01th 2013 May 01th 2016 Surabaya

Certificate Grade of License Number Issued Date Expiry Issued by


Indonesia License ATT D 6202078185350214 August 14th 2013 Jakarta

1. Marine Certificate / SOLAS / MARPOL / OTHER


Certificate Number Issued Date Expiry Date Issued by
IND PNM
Basic Safety Training 6202078185010113 April16th 2013 Jakarta
Proficiency Survival Craft &
6202078105040113 May15th 2013 Jakarta
Rescue Boat
Medical First Aid 6202078185070113 May20th 2013 Jakarta

1. Expeerienced On Board
Name of Ship GRT Company Rank Type of Ship Sign on Sign off
KM. INTAN
760 PT. SARI BUMI A/B General Cargo 17-10-2009 10-05-2010
MEGAH
PT. MANDIRI
MV. DINAMIS 9 584 A/B General Cargo 22-09-2010 11-06-2011
SEJAHTERA ABADI

Hendra

Signature Crew

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