APLICATION FORM

Personal Data Full Name Place / Date Of Birth Adress ABU THOLIB Ponorogo, 8 Oktober 1987 Dukuh Coper Kidul RT 001 RW 002 Desa Coper Jetis Ponorogo Material Status Height / Weight NO MARRIED 167 / 58 Kg Phone 081234837912

Document Details Of Document Seaman's Book

Number Y.083266

Date of Issue 02 - 11 - 2011

Expire Date 01 - 11 - 2014

Issue at SURABAYA

Certificate Certificate of Complatency 1. ATT D

Number 6201099471T60711

Place / Date of issue JAKARTA

Short Course Certificates Certificate Basic Safety Training Survival craft & rescue boat Number 6201099471010511 6201099471040512 Issue Date 25 Oktober 2011 6 Februari 2012 Expire Date Isssue At SURABAYA SURABAYA

ACTIVE SEA SERVICE Number 1 2

Function Oiler Oiler

Trade Area A.P.I A.P.I

Ship's name GT and kw KM. MITRA ABADI 1 KW : 800 PK GT : 674 KM. TANJUNG BARU KW : 800 PK GT : 666

From / Until 21 - 04 - 2010 26 - 08 - 2011 23 - 04 - 2012 19 - 07 - 2012

SINCERELY YOUR

ABU THOLIB