Personal Data Form

Atlas Services Group Singapore Ltd Pte

DATE : March 14, 2023 Please fill in all fields applicable

Title * : Mr.
Surname : Wathun
First Names : Lord Angelo Call Name : Lord
Middle Names : Alfaed Yubilio
Address : Cut Nya Din street, no. 5A
:
Country : Indonesia
Home Telephone No. : (0354) 686 494
Alternative Telephone No. : +62 858 1544 5869
Mobile / Pager No. :
E-mail address : lord17220@gmail.com
NI / Finn number (If applicable) :
Nationality : Indonesian
Jendral A. Yani Intl. Official Residence : Kediri City
Nearest Main Airport : Airport Time to Airport : 45 minutes
Date of Birth : September 11, 2000 Place of Birth : Kediri Residence

Marital Status * : Single

Spouse’s Name : Date of Birth :
(This is required for Norwegian and Danish tax purposes and must be your legal marital status)
Next of Kin : Lusia Machdiana
Relationship : Mother Telephone No : +62 812 8614 8499
Mother's Full Name : Lusia Machdiana
Mother's Maiden Name : Lusia Machdiana
Father's Full Name : Bonefasius Kudus Watun
(This is often required for Visas)

Corporate info:
Own Limited Company Name :
Registered Company Address :
:
:
Country of Registration :
Company Registration Number :
Date of last Corporate Tax return:

Travel Document Info:

Passport No.1 - Country : Indonesia Number : E1983343
Date issued : January 16, 2023 Expiry Date : Januray 16, 2033
Place issued : Kediri

Passport No.2 - Country : Number :

Date issued : Expiry Date :
Place issued :

Visa 1 - Country : Expiry Date :

Visa type :
Visa 2 - Country : Expiry Date :
Visa type :

Seaman’s Book : Indonesia Number : H094325

Expiry Date : January 26, 2026 Country : Indonesia
Discharge Book No. : Number :
Expiry Date : Country :

Driving License : Motorcycle Number : 1459-0009-000321

Expiry Date : October 04, 2027 Country : Indonesia
Frequent Flyer Membership : Number :
Languages Spoken : English

* Please delete / strike non-applicables

QAD010R • Issue 1 • July 2015 1 of 2 Approved Director

Personal Data Form
Atlas Services Group Singapore Ltd Pte

Safety
Blood Group * : A Rhesus * : Positive

Safety Course Held at :

Approval * : NOGEPA/OPITO/OLF/STCW/Other
Date completed : Expiry Date :
Course Type :
Medical Held at : KLINIK RAHB INDOSEHAT 2003
Approval * : STCW
Date of Examination : December 29, 2022 Expiry Date : December 29, 2023
Medical Conditions/Allergies : Fit
Medication : -
Doctor's Name : dr. Dyah Widowati Rahajoeningsih
Doctor's Address : Anjasmoro Raya no. 38-A/7 Karangayu, West Semarang
Doctor's Telephone number : (024) 7617189

Taxation and Bank Details

Tax Status * : Own Company / Employee of Atlas / Self Employed
NI/Social Security Number :
VAT Number:
UTR Number:

Other information
Qualifications :
:
:
Vocational training :
:
:
Additional Documents :
Safety log books, IMCA Log
book, etc.
Please provide Type, Number
and Expiry date

Background Security Checks

Do you have any criminal convictions (not spent)* : NO
If yes, please provide further details:

Personnel may also be asked to obtain a "Certificate of Non Prosecution" for visa purposes

I, the undersigned, declare that the above information is true and correct.
I give permission for my personal data to be used for recruitment purposes.

Signature: Print Name: Date:

PLEASE RETURN THIS FORM INCLUDING ALL COPIES REQUIRED

=====================================================
Company Registration Form Passport copies Disc harge Book
Proof of Corporate Tax return VISA copies Additional Documents

Self Employment / other Seaman's Book 4 Passport Photographs

Safety Certific ate Vocational training

* Please delete / strike non-applicables

QAD010R • Issue 1 • July 2015 2 of 2 Approved Director