PT Perusahaan Pelayaran EQUINOX

APPLICATION FORM
Photo

A. PERSONAL
Name

Date of Birth & Place

Nationality

Religion

Address

Telephone number

Email Id
Marital Status

:
:

KPI No.

Number of children

Height
Weight

:
:

Next of Kin (NOK)

Address

Size of working cloth :

Telephone number

Size of Shoes :

Email Id

Position applied :

B. PERSONAL DOCUMENT
Description

Number

Date of issue

Date of expiry

Description

Date of issue

Certificate No.

Validation

Passport
Seaman's Book
Flag State License

C. COURSES

Advanced Tanker Safety - Oil

Advanced Tanker Safety - Chemical
Advanced Tanker Safety - Gas
Tanker Familiarization
COW - IGS
Deck Watch Keeping
Engine Watch Keeping
Medical First Aid Training
Medical Care
Advanced Fire Fighting
Basic Safety Training
Survival Craft Rescue Boat
GMDSS - GOC
ARPA simulator
Radar Simulator
ISM Code Training
Bridge Team Management
Bridge Resource Management
Engine Team Management
Ship Security Officer (SSO)

PT PP Equinox Application Form

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D. MARITIME LICENSE
Type

Certificate No.

Date of issue

Issued by

Period

Management

E. SEA SERVICE RECORD

Position

Vessel

IMO type

GRT/BHP

Flag

F. MEDICAL RECORD
Last Medical Check Up:
Date Taken
MCIS
Extensive
Medical

Date Taken
Vaccination

Simple
Test Drugs

Yellow Fever
Cholera
Typhoid

Clinic

Form
Clinic

G. INTERVIEW RESULT
Personality

Work understanding

English

Ability to Expr Himself

Attitude

Record of Experience

Team Work

Education

1 : Poor

2 : Below Average

3 : Averange

4 : Good

5 : Very Good

6 : Excellent

Date,

Applicant / Signature

PT PP Equinox Application Form

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