Synergy Maritime Recruitment Services Pvt. Ltd.

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APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

Present Rank : 3e Rank Applied for : 3e

Surname : yuhardi suparman Tel No. 081315885334

Name yuhardi Alternate Tel 021 86613404

Email ID yuhardihegel@gmail.com Skype ID White background. 80%

Face
Date Of Birth (DD/MM/YYYY) 07/Mar/1974 Place of Birth : jakarta

Nationality : indonesia Marital Status : married

Date of Availability : Boiler Suit Size : XXL

Height(cms) 165 Weight(kgs) 87 Blood Group Shoe Size : 10

kp.bulak jaya rt 12/08 pulogebang cakung jakarta timur
Address :

Nearest Airport

PAN No for
AADHAR for Indian Indian MUI/NUSI or any other
Nationality Nationality Union Membership No

English Language Proficiency : Speak Good Read Good Write Good

Documents Number Place of Issue Date of Issue Date of Expiry

Passport c 5792472 jakarta 1 November 2019 1 November 2024

National CDC / Seaman Book E 127032 jakarta 17 okt 2019 17 oktober 2021

Biometric SID

U.S. Visa C1/D

Schengen Visa

Documents Grade/ Number Issuing Authority Date of Issue Date of Expiry

Level
CLASS 3
National Certificate of
Competency (COC)
6200489083S30115 jakarta 6 November 2015 Unlimited
CoE - Panama

CoE - Marshall

CoE - Singapore

CDC - Marshall Islands

CDC - Panama

CDC - Liberia

INDoS No

STCW Certificates Number Name of MTI Date of Issue Date of Expiry

PSSR

PSCRB 6200489083040719
28 Nov 2019 1 Nov 2024
PST / BST 6200489083010719
28 agustus 2019 agustus 2024
AFF/ FPFF 6200489083060716
21 Feb 2016
EFA/ MFA/ Medicare 62004890830700716
11 Feb 2017 unlimeted
SSO/STSDSD 6200489083240214
3 Mar 2014 unlimeted
High Voltage Training

National Endorsements Number Issuing Authority Date of Issue Date of Expiry

(Where applicable)

GMDSS

Basic/Adv Oil 6200489083410719

Endorsement 28 Nov 2019 1 Nov 2024
Basic/Adv Chemical 6200489083390719
Endorsement (BOCT) 28 Nov 2019 1 Nov 2024
Basic/Adv Gas 6200489083370719
Endorsement (BLGT) 26 Nov 2019 1 Nov 2024
Navigation & Main Date of Expiry
Engine Training Number Name of MTI Date of Issue (Where applicable)
BTM
ECDIS - Generic
ECDIS - Type Specific I
ECDIS - Type Specific II

Ed 01 Rev No 0
FORM : M 01 Page 1 Of 2
Date:10-Jan-2020
 Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

ME Engine
RT Flex
Any Value Added Course /
Company Specific Course
Academic Background
Qualification Name of Institution Board / University Date of Passing
10th Std (SSLC) /Equivalent
12th Std (Hr. Sec) / Equivalent
Pre Sea Training
Any other Qualification
Family Details - all dependant

No. Name Relation D.O.B Sex Passport No Place of Issue Date of Issue

1 sri rejeki wife female

2 hegel son
3
Previous Sea Experience (All Sea Service details from Cadets/Jr level. List recent vessel first)
Deck (Trade & DWT) Period Dates
Vessel's Name Engine (Type & BHP) Type of Vessel/Flag Company's Name Rank
TEU (Containers) From To

KM MULTI ALFA wuxi gt 2963/1763 kw container indonesia PT MULTI 3e 20.12.2012 02.04.2013

MT FERGIE FEBE mitsubishi gt 5025/4900 hp oiltanker indonesia PT MARGO 3e 04.03.2013 26.08.2013
MT AE GAS mitsubishi gt 3565/2700 hp tanker gas elpiji indonesia PT TAN 2e 01.10.2013 05.05.2014
ASEAN GAS mitsubishi gt 3239/2800 hp tanker gas elpiji indonesia PT TAN 3e 17.07.2014 30.10.2014
MT TRIAKSA hitachi b&w gt 1374/1600 hp oil tanker indonesia PT AKSA 3e 04.11.2014 02.12.2015
MT WILPOWER mitsubishi gt 9739/4000 hp tanker gas lng indonesia PT TIMUR SHIP 3e 29.04.2016 27.09.2016
MT WILENERGI mitsubishi gt 102390/29420 hp tanker gas lng indonesia PT TIMUR SHIP 3e 08.12.2016 03.06.2017
MT WILPOWER mitsubishi gt 102390/29420 hp tanker gas lng indonesia PT TIMUR SHIP 3e 03.08.2017 05.02.2018
MT QUINTA cumin gt 4096/2 × 1765 kw oil tanker indonesia PT TIMUR SHIP 3e 28.05.2018 18.10.2018
MT AE GAS mitsubishi gt 3565/2700 hp tanker lpg indonesia PT TAN 2e 02.06.2019 10.01.2020

KM SALLY FORTUNE wartsilla gt 5023/4000 kw container indonesia PT BUMI LAUT SHIPPING 3e 20.05.2020 23.11.2020

Last Employer name KM SALLY FORTUNE PIC & Contact No / Email ID:
If yes, Candidate to submit self-declaration background security ch
Break in sea service of more than 12 months from last sign off Yes / No
Form M02 at the time of Evaluation
Summary of Sea going Experience
For all Officers: Period served on (yy/mm)
BULK CNTR OIL TNKR CHEMICAL

Handymax Panamax Capsize Centre- Feeder Ctnr >8000 Ctnr >14000 Prod. Tanker Aframax VLCC OIL& Chem

For Engineer Officers only : Period served on (yy / mm)

Sulzer B&W MAN Pielstick UEC Doxford Steam UMS CPP Cranes

Pump Experience (in months) for All Tanker Seafarers

FRAMO COP

If Yes, in New
Have you been on board vessels during: Drydocking Yes which Rank 3E Construction Yes / No

Have you been involved in any Incidents of Grounding / Fire / Explosion / Collision / Abandon Ship / Rescue / Major oil Pollution / Drug Smuggling / No
Towed or Towing another vessel. If yes, please specify
NO
Have you been involved in a court of Enquiry for a Maritime accident ? If yes, please specify
NO
Have you ever been involved in a criminal case : If yes on any of the above , give details:
NO

Has your present or previous certificate ever been suspended / revoked ? If yes, give details:

NO
Do you suffer or have suffered from : Diabetes / High Blood Pressure / Hepatitis / Epilepsy / Nervous Disorders/ Disturbed Vision Or Hearing /
Vertigo If yes, give details :

Are you a habitual user of Drugs / Narcotics / Excessive Alcohol. If yes, give details: NO

Have you previously worked with multinational workforce? If Yes, What nationalities: Yes, Indian, Philipino, Bangladesh

Ed 01 Rev No 0
FORM : M 01 Page 2 Of 2
Date:10-Jan-2020
 Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

Declaration by the Applicant:

I understand that a strict medical examination including Drug and Alcohol test as per company requirements is a condition of my employment and I express my willingness to be examined.
I undertake to provide the company’s medical officer full details of my previous medical history. I agree that the decision of the company medical officer is final.
I declare that there are no criminal/ police investigations in progress against me.
I confirm that all my travel documents are valid and in order. I understand that if my travel Documents become invalid or restricted at any time during the course of my employment and cannot be revalidated
under normal process, the contract of employment will terminate and all costs of repatriation will be borne by me.
I am /am not presently employed elsewhere.
I am aware that Synergy Maritime Recruitment Services Pvt Ltd., does not have any agents in India for employing Seafarers.
If my application is successful, I will be available to report at your office on or after:________________

If this application sent through candidate's email id, applicant's signature is not required. Candidate should submit the signed application form during the evaluation process/PJF

Name Of Applicant YUHARDI Date 9 des 2020 Signature of the Applicant

Ed 01 Rev No 0
FORM : M 01 Page 3 Of 2
Date:10-Jan-2020
 Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

White background. 80%

Face

Nearest Airport Jakarta

Date of Expiry

1 November 2024

17 oktober 2021

Date of Expiry

Unlimited

Date of Expiry

1 Nov 2024

agustus 2024

unlimeted

unlimeted

Date of Expiry
(Where applicable)

1 Nov 2024

1 Nov 2024

1 Nov 2024
Date of Expiry
(Where applicable)

Ed 01 Rev No 0
FORM : M 01 Page 4 Of 2
Date:10-Jan-2020
 Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

Grade /
Percentage

Date of Expiry

Months/Days Reason for S/off

finish contract
finish contract
finish contract
finish contract
finish contract
finish contract
finish contract
finish contract
finish contract
finish contract

bmit self-declaration background security check

of Evaluation

CHEMICAL GAS

Parcel Gas

MAK / 4-Stroke ME B/C

If Yes, in which
Rank

No

NO

NO

NO

NO

NO
Yes, Indian, Philipino, Bangladesh

Ed 01 Rev No 0
FORM : M 01 Page 5 Of 2
Date:10-Jan-2020
 Synergy Maritime Recruitment Services Pvt. Ltd.,
APPLICATION FORM RPSL/CHN/033 Valid till 4th July 2024

llingness to be examined.

of my employment and cannot be revalidated by me

uation process/PJF

Ed 01 Rev No 0
FORM : M 01 Page 6 Of 2
Date:10-Jan-2020