LERUS SDN.BHD.

TRAINING COURSE APPLICATION FORM

Please complete the form in BLOCK CAPITALS.
COURSE APPLIED FOR:
Course Title: DP MAINTENANCE Date of course:

PART A: DETAILS OF APPLICANT (as they appear in your seaman book)

Title: Mr/ Mrs/ Ms/ Miss/ Other (Please specify): Mr Male / Female (circle one)

Family name: BIN AZAMI Date of birth: 16.01.1990

First name(s):NOOR Nationality: Malaysian

Middle name: AIMAN Rank/ Job title: THIRD ENGINEER

Home address: Home phone:

D-1-5 BLOCK RAPIS, LAS PALMAS APT, JALAN DESA RIA,
BANDAR COUNTRY HOMES, 48000 RAWANG Mobile phone/ Cell phone: +60132422383
SELANGOR DARUL EHSAN e-Mail: aimanazami@ymail.com
Country: MALAYSIA
Most of our courses require a good level of written and spoken English. Please indicate your proficiency in English:
1 = poor 5 = excellent
Write (5) Read (5) Speak (4)

Do you have any medical conditions we should be aware of?

Yes / No If “Yes”, please give details

Person to be notified in an emergency.

Full Name Address Phone Number Relationship
Nurul Hanis +60132721067 Spouse

Accommodation (Please tick appropriate): Required Not Required

PART B: DOCUMENTS OF APPLICANT (Please provide applicable)

Document Grade Number Date of issue Place of issue Valid until
2335005638A 07/11/2008 Port Klang No expired date
Seaman’s Book
Second Engineer Officer of 23111112Ell 17/07/2023 Port Klang 16/07/2028
Certificate of
3000kW or more Unlimited
Competency
Trade Voyages
Endorsement

DP Certificate

Have you attended any DP Courses before? If “Yes”, please give details.

Do you have on hands IMCA or NI Logbooks? If “Yes”, please give details.

PART C: EXPERIENCE OF APPLICANT

How long have you been in the industry? 9 years Length of time in current role:
Please state the last 3 vessels:
Owner or
Vessel Type/DWT Flag DP Class Engine/BHP Rank From To
Manager
Safeen HLPL/17650 Marshall DP2 Wartsila/24000kW Safeen Third 2/12/2023 19/01/2024
3000 Island Feeder Engineer
Company
Sapura DSV/1828 Port Klang DP2 Wartsila/2475 Sapura Third 29/09/2023 03/11/2023
Jane BHP Engineer
Safeen HLPL/17650 Marshall DP2 Wartsila/24000kW Safeen Third 21/09/2022 03/11/2022
3000 Island Feeder Engineer
Company

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PART D: DETAILS OF PAYMENT
Payment Method (Please tick appropriate) Cash Invoice
INVOICING DETAILS (If applicable)
Organisation name: Noor Aiman Bin Azami

Address: Telephone number:

D-1-5 BLOCK RAPIS, LAS PALMAS APT, JALAN DESA RIA,
BANDAR COUNTRY HOMES, 48000 RAWANG Mobile phone/ Cell phone: +60132422383
SELANGOR DARUL EHSAN e-Mail: aimanazami@ymail.com
Country: MALAYSIA

PART E: General Conditions:

Registration and application:
Acceptance onto a Training Course at Lerus SDN. BHD. is subject to a successful application procedure (including but not limited the following: completion of
application form, meeting of prerequisite training requirements and passage of interview if required,). You will be notified at the end of the procedure
whether or not you can be accepted onto the course. Final reconfirmation will be made upon full payment the Training Course to be carried out by
Applicant.
Payments:
Payments may be made by all major credit and debit cards, except American Express cards; cash payment is acceptable or Lerus SDN. BHD. will provide
Invoice for Organisation mentioned in Part D. Credit is not granted to private delegates or to individuals under any circumstances. Balance of payment is due
no later one week before the start of the course.
Cancellation fees:
All cancellations must be made in writing. For cancellations received up to 20 working days (4 weeks) prior to the start of the course Lerus Training will
refund 100% of the course fee. Cancellations received after 20 working days (4 weeks) till 5 working days (1 week) before the start of the course will be
charged the 50% of course fee. Full course fee will be charged for cancellation within 5 working days (1 week) prior the start of the course. If the delegate
fails to attend the course, the whole course fee will be charged. If you cancel or withdraw after the start of the course, no refund will be given. Non-
disclosure of a health problem before the course starts means that no refund will be possible once the course commences
Amendments:
Any amendments must be made in writing. Amendment of the booking within 5 working days (1 week) prior the start of the Course and shift of intended
Course within the three months of the previously booked, will lead that in addition to the charged original Course fee the subsequent Course should be paid
with additional 50% of Course fee and no further changes of Course date or name of delegate on the booking will be permitted. Other amendments to be
accepted without any charges. Should the required minimum number of candidates not be reached, the course will be postponed to a future date.
Candidates will be kept fully informed of projected course details and monies will be refunded. Whilst every endeavor is made to ensure courses are run as
scheduled, on occasions there is a need to postpone or cancel a course. In such circumstances, all fees paid in advance will be held for use against a future
course or can be requested to be refunded.
Insurance:
Candidates are not insured by Lerus SDN. BHD. against illness, accident, theft or any loss of personal effects. Lerus SDN. BHD. and its principals cannot accept
responsibility for any accident occurring during the course, on or off the center premises or during activities.
Place of Jurisdiction:
Place of jurisdiction in any dispute: the courts of Kuala Lumpur, Malaysia.
Confidentiality Policy:
Lerus Group is committed to protecting the privacy of its customers and the security of their personal information. We collect information clearly and
transparently and communicate how we will process the data. You can find out more about our Confidentiality Policy at our website.

I hereby declare that all information supplied by me is to the best of my knowledge true and correct. I understand and agree to be bound by the General
Conditions stated herein. I agree to be bound by the payment time table. I have read and agree to abide by the conditions pertaining to refunds.
I understand and agree with LERUS GROUP Confidentiality Policy. I agree that my personal information may be shared to third parties for the certification and
auditing purpose.
Signature of applicant: Date: 22.01.2024

All the rows below are for LTC Official use only

Events Secretary / Booked & informed Acceptance letter/date Reconfirmation call Rejection letter
Ch. Instructor
(Please record the dates)

Cancellation by applicant Date Reason % refund/approval Refunded

Finance Officer: Fee Invoice sent /date Payment received Cash received/ date
status? /date
Date:
(Please record dates)

Instructor’s Accepted Not accepted Other comments

review/response

Top Management Approval

for discounted fee

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(%, date, name)

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