SEAFARER EMPLOYMENT APPLICATION FORM

POST APPLIED FOR : MASTER

(Please read form carefully before attempting to fill in, where not applicable state N.A.. Copies of certificates/testimonials etc. should be attached to the form.)

Agency Name :

A) Type of vessel applying for : (Plase Tick)

Tanker (>20000 DWT) GP Tanker (< 20000 DWT) Bunker Barge

(I) PERSONAL PARTICULARS

Last/Surname Name KURNIAWANGiven Names (as in passport)ANDI EKO KURNIAWAN

Present Address: Jln.RH.Fisabilillah - Mutiara Villa # block C-2 Tg.pinang Indonesia.Email:andkurniawan@gmail.comSkype ID:Shoe Size: 42Overall Size: XXL

Phone No:(Country Code)+(Area Code)+(Tel No)

Mobile No:(Country Code)+(Area Code)+(Mobile No)+62-81390544666 , +62-85724777000

Date of Birth24 Feb 1974Place and Country of BirthTg.Pinang IndonesiaNationalityIndonesiaReligionMoslemMarital StatusMarried

( II ) FAMILY BACKGROUND

Next of Kin Rini LestariRelationship (Husband/Wife if married;Father/Mother/Guardian if single)Wife

Address of Next of Kin: Jln. RH. Fisabilillah - Mutiara Villa # block C-2 Tg.pinang Indonesia

Telephone No :Mobile Phone No :+62-85264166295Email :

Childrens Name (if applicable)SexAgeOccupation

2)Khemal AkbarM12Study

3)Keisha AndaniF8Study

4)

(III) HIGHEST ACADEMIC QUALIFICATION

FromToInstitutions/Universities attendedQualifications

Oct 2012April 2013Merchant Marine University STIPClass 1 ( ANT 1 )

Jakarta

(IV) DOCUMENTS AND CERTIFICATES

Personal Document Document No.Issue DateExpiry DateIssued by

International Passport with 2 blank page26 july 201226 july 2017KBRI Spore

Seaman Passport (If Any) - - -

Discharge book (CDC) - - -

STCW Certificate

Certificate Of Competency (COC)Indicate Grade : __________________

A IV/2 General Operators Certificate (GOC) : (Deck Officers only)

A V/1-1 Oil Tanker Familiarization 30 april 2007 -STIP JKT

A V/1-1 Chemical Tanker Familiarization - - -

A V/1-2 Advance Oil Tanker 25 june 201225 june 2017STIP JKT

A V/I-2 Advance Chemical Tanker - - -

A VI/1 Safety Familiarization & Basic Safety Training20 march 2007 -STIP JKT

A VI/2 Proficiency in Survival Craft and Rescue Boat Other Than Fast Rescue Boat16 june 2014 -Bina Sena JKT

A VI/3 Advance Fire Fighting20 march 2007 -STIP JKT

A VI/4-1 Medical First Aid13 des 2001 -STIP JKT

A VI/4-2 Medical Care25 jan 2002 -STIP JKT

A VI/5 Ship Security Officer03 may 2011 -STET Spore

A VI/6 Security Awareness Training - - -

A VI/6 Seafarers with Designated Security Duties - - -

Ship Handling Certificate (For Master) - - -

ECDIS Training Certificate - - -

Bridge / Engine Team ManagementMarch 2014 -BP3IP JKT

MEDICAL AND VACCINATION

Medical Examination (MLC )June 2013 -Sea Care spore

Yellow Fever - - -

Cholera Vaccination - - -

(V) DETAILS OF SPECIAL TRADE * delete whichever is not applicable

Experience on Inert Gas Tanker: YES / NO *Experience on Chemical Tanker: YES / NO*

Experience with USCG (TVEL): YES / NO*Experience on STS: YES / NO*

PSC Experienced: NO Vetting Inspection Experienced: NO

Trading Area: Spore waters and West Msia waters

Types of Cargo experience With: MGO and MFO

Experience with Nationalities :

Total Sea Service time on Oil Tanker : 132 mths

Total Sea Service time on Chemical Tanker : NONE mths

Total Sea Service time on All Tanker : 132 mths

Total Sea Service time Present Rank : 60 mths

Total Sea Service time On Present Rank: mths

Total Sea Service time : 168 mths

mths

(VI) ADDITIONAL INFOMATIONS

Command of EnglishPoorSatisfactoryGood

CES Test Result: %Marlin Test result: %

Last Company Name:Southernpec Ship MgmtPerson In Charge:Capt. Xiao rong booPhone: -Email: -

Reason for Leaving Last Company : Finish contract

Last Salary: S$ 6500 Readiness:

(VII) DETAILS OF SEA SERVICE

CompanyVesselVesselGRTType ofBHP/RankPeriodTotal

NameTypeEngineKWFromToMonths

(VIII) MEDICAL HISTORY / BACKGROUND

* delete whichever is not applicable

Height : Weight: Chest Span :

a)Do you have any history of family or personal illness such as Tuberculosis, High Blood Pressure, and Mental Illness etc?Yes/No*

Yes/No*

Yes/No*

Yes/No*

Yes/No*

b)Have you ever been hospitalised, operated or currently undergoing some kind of medical treatment? Yes/No*

c)Do you have an emotional or physical handicap (disability)?Yes/No*

d)Have you ever been charged in court for any offence? Yes/No*

e)Have you ever served on or applied to Ocean Tankers (Pte) Ltd or affiliated concerns of Ocean Tankers (Pte) Ltd?Yes/No*

f)Have you been involved in a maritime incident before?Yes/No*

If any of the answer is Yes, please give details below

a.Only blood pressure, but under control and medical treathment by doctor and medicine.

b.Hospitalised and operated in spore hospital in MEH by motor bike accident on may14

(IX) DECLARATION BY APPLICANT

I certify that all statements given on this application are correct and true to my knowledge. I also understand that falsification or misrepresentation ( intentionally or unintentionally ) in this or any other personnel records can result in my immediate dismissal and forfeiture of all wages, allowances and benefits if I am employed by the Company. I do agree to submit myself to a thorough medical examination, which I must successfully pass as one of the conditions for being accepted for employment.

Andi eko kurniawan/ 19/9/2014 Signature of Applicant / Date

Recent Passport

Photograph

2Note: Retention period of completed form is permanent if employed.

OT/C/CRW/1113/001

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