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Employment Application Form

sea chefs Cruises Ltd

sea chefs River Cruises Ltd
sea chefs River Management Ltd

lnterview No:. _ _. Crew l.D.:

Position applied for: Bar Utility Department: F & B Date: Y

Surname: MAT HAFI First Names: RUDIYANTO
Dsn. Karang ir4alakah Ds. Glagga Age
Add Tess
Kec. Arosbaya, Bangkalan Sex Male

Name Building/Block l\ilobile Telephone No

+ 62857 46592019
City/Town Bangkalan ome Teleohone No
Z' Code 69'1 51
E-mail address
Count INDONESIA
Date and Place of Birth Baiigkalan, Oct-o1-'1 993 Nationality lndonesia
c6370409 Tanjung Expiry date
lssue date 8-02-20 lssue place:
Perak
F 288882 lssue date: l 29-11-19 rssJe prace, a Expiry date
J l\4arital status: Sjngle Relationship ster
z Luluk Address ' Dsn. Karang Malakah Gl agSa
o
a
, Next of Kin:
elep hone No +62857327 13018
d Present
uI ince when
o- j
Ever applied to this ,l
NO When? ,l
before?
-l
Main departure SURABAYA AIRPORT
Recruitment Agency: PT, DEMARIN
Have you ever had any difficulties with the authorities, in any Jurisdiction or Country {i.e. Police, Customs,
lmmigration etc.)? And if so, for wtrat reasons? NO

This information is required to provide safety and security onboard our vessels and compliance with relevant
Authorities' requirements. Once the information provided is ve.ified it will be destroyed and no record will be

I consent to the provision and verification of my criminal record X

, I DO NOT consent to the provision and verification oi my criminai record

Reason for
Position: Name and Address of Employment: From - To (Dates):
F Leav
zITJ Utili Feb-05-2020 At Present
Eir>
Bar Surab a Suite Hotel
Equ-liliry Garden Paiace Hotel Suab a Oct-l1-2018 Nov-28-2019 sh Conffact
bP
JI" Bar U I\,{V. KAMBUNA Sep-20-2017 Jul17-2018 Finish Contract
o-=
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IIJ

Spoken Written Reading

Fair Well Excellent Fait Well Excellent Fair Well Excellent
Q ENGLISH n
UJ
o GERMAN
FRENCH
3 ITALIAN
o
z SPANISH
J RUSSIAN
OTHER i

F7.3 Employment Application Form lssue: 4 / lssue datet 24-05-2018 113

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Employment Application Form

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sea chefs Cruises Ltd
sea chefs River Cruises Ltd
sea chefs River Management Ltd

z Education Name and Place of School Years Attended Year Graduated

F Hioh School SMKN 1 rArosbqya 1 0-Jun-2014 02-tM ?Y:2 o17
College
o
ul
Trade, Business
or Other School

SCHENGEN
MULTI / SINGLE lssue date: lssue place Expiry date

o usA (c1lD1) lssue date lssue place: Expiry date

5 TYPE D PERMIT lssue date: lssue place Ex prry date

Duration of
Certiticate fo; 5Ba-Gcr'nE Oi?ry No Date of lssue Expiry Date
Traini
U>
trl Basic Safety Training
F Section (A-Vl/1 .2)
@
o Seclion A-Vl2 (par. '1,2,3,4,5) (state which paragraphs)
= tr Sqqliqn A-VJ3 (pgf,..1,?3,4,q (stqle wrliqh pq!'agrqphs)
E
tu Crowd l\ranagement
o Crisi nt

Are a doctor's care with medication? YES i lNo x

lf yes please

Do have an reca medical YES .NO x

lf yes please specify
J
Io Are you on any meclication? YES NOX
j
:
lf yes please specify:
UI that would limit your ability to pertorm the iob you are
l
l
!
= seeking?
Hei 172 Cm WejS.tlti 67
i state if defect in:
Heari GOOD
I Vision: GOOD
SpeeCn: GOOD

We require your ntedical information for our legal obligation to conform with relevant laws, regu,ations and
intemational conventions which makes it obligatory for the company to hold and process such information.
(lntemational Maritime Organization {lMO}, lntemational Labor Organization (lLO}, Maritime Labor Convention (MLC},
The lnternational Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW). This
obligation is based on the obligatory medical examinations for issuance of the Fit-for-Duty Certificates. lf your
employment application is not successful, your medical data will be immediately deleted.

I consent to th x
I DO NOT consent to the provision and process of my medical data

I have r€ad and understood the company's Privacy Policy on

Collection, Processing and Protection of Personal Data x

F7.3 Employment Application Form lssue: 4 /lssue datei 24-05-2014 213

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Employment Application Form

sea chefs Cruises Ltd

sea chefs River Cruises Ltd
sea chefs River Management Ltd

I confirm that the above is to the best of my knowledge and belief correct.
I also understand that any false statement above is reason form dismissal if engag

,".,?/1{'u Signature of applicant:

Please attach a copy oi the following documents:

No Documents Sea4oin River Ex Comments

1 Pass rt , name, expiry and visa
2 Seaman's Book I
V
3 Vaccination Book
4 Qualif ication Certif icates ,2 l
5 Tra jning Certificates I

Su
Name of interviewer: t&a.5r Dat€
Positions
ER: FR: ITA: SPN: RU ofH:
tz Evaluation
Criteria: Comments:
o 1

IIJ 2
o
f, Experience 3
J
Knowledge 4
z
u
ul
Vessels
F Overall 1 2 4 5 1

Evaluation: Poor Fair Very Good Excellent 2

=
lnterview Passed - Passe Passed -
Failed 3
outcome: Contract offered d by Contract ofiered No offer
re of lnterviewer :

F7.3 Employment Application Form lssue: 4 / lssue date: 24-05-2018 313