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APPLICATION FORM

( CURRICULUM VITAE )
I apply for job : Engine Department

I. Personal Data
Name RAHMAD HADI PRAWIRA
Place & Date Of Birth Medan, 28 April 1981
Gender Male
Religion Moslem
Permanent Address DSN Krajan
Desa Ketapang, Kab. Banyuwangi 68451
Country Indonesia
Nationality Indonesia
Mobile Phone 081336538883/081332223454
Marital Status Single

II. Seafarer's Identify Document


DOCUMENT NO OF DOCUMENT PLACE & DATE OF ISSUED DATE OF EXPIRE
SEAMAN BOOK W009790 Surabaya December 18,2008 December 17,2011
PASPORT R812507 Surabaya April 25,2008 April 25,2013
MEDICAL CHECK UP I104954 Surabaya April 26,2008 April 26,2010

III. CERTIFICATE OF COMPETENCY


DOCUMENT NO OF DOCUMENT PLACE & DATE OF DATE OF EXPIRE
ISSUED
ATT-D 6200091893T60502 Jakarta,March 21,2002 Unlimited
ATT-V 6200091893T50510 Jakarta,July 27,2010 Unlimited
Endorsement ATT-V 6200091893TE0510 Jakarta,August 6,2010 August 6,2015

IV. CERTIFICATE OF COMPETENCY


NO CERTIFICATE CERTIFICATE NUMBER PLACE & DATE OF ISSUED
1. BST 6200091893010304 Semarang,July 19,2010
2. SCRB 6200091893040304 Semarang,July 19,2010
3. AFF 6200091893060307 Semarang,Juni 07,2007
4. MEFA 6200091893070307 Semarang,Juni 06,2007
5. MC 6200091893080510 Surabaya,July 07, 2010
6. TFC 6200091893090510 Surabaya,July 09,2010

V. SEA SERVICE RECORD


NO VESSEL NAME VESSEL FLAG COMPANY RANK GRT HP SIGN ON/SIGN OFF
TYPE
1. Rahmat Sejati KLM INA RSJ OILER 340 240 070201 - 230801
2. Bhaita Caturtya LCT INA LSN OILER 580 2X420 060903 - 061205
3. Trisna Dwitya LCT INA LSN OILER 800 2X690 071208 - 150408
4. CJN III-2 KM INA MERATUS OILER 3000 1650 080608 - 131108
5. Marigold Star KM INA MERATUS OILER 5345 6000 310109 - 281009

Sincerelly Yours,

( RAHMAD HADI PRAWIRA )

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