SEAFARER’S APPLICATION FORM

Position Quarter Master Readiness Any Time

First Name Yosep Marital Status Single
Last Name Istiaji Nationality Indonesia
Birth Date June 05, 2000 Birth Place Petarukan, Pemalang
Serang, Kedokanjati, RT 06 RW 01, Phone Mobile 085 6403 07522
Home Address Petarukan, Pemalang Regency, Central
Email yistiaji007@gmail.com
Java, Indonesia

Next of Kin Sungkowo Relation Father

Serang, Kedokanjati, RT 06 RW 01,
Contact
Address Petarukan, Pemalang Regency, Central City Pemalang Country Indonesia 0882005354764
Java, Indonesia details

Seaman’s book Issued

No Valid Until
& Pasport Place date
Seaman’s Book l 040472 Cilacap July 12, 2023 July 12, 2028
Medical cek up 6212333525MC3123 Poliklinik PIP Semarang July 25, 2023 July 24, 2025

Certificate of Competency
Type of Certificate Certificate number Place/date of Issued
Ratings forming part of navigational watch 6212333525330324 Semarang 08 January 2024

Document of STCW Manila 2010

No
Document No Place Issued/date Expired Date
1. Basic Safety Training (BST) 6212333525017123 Pemalang/ June 23, 2023 July 05, 2028
2. Security Awareness Training ( SAT ) 6212333525310323 Semarang/ July 31, 2023 July 31, 2028
3. Advanced Fire Fighting (AFF) 6212333525060323 Semarang/ August 01, 2023 August 01, 2028
Seafarers with Designated Security
4. 6212333525320323 Semarang/ August 08, 2023 August 9, 2028
Duties (SDSD)

International Certificate of Issued

No of Vaccine Valid Until
Vaccination Place Date
Vaccination for Covid - 19 Pfizer Booster Indonesia Mei 17, 2023 Unlimited

Best Regard,

Yosep Istiaji