SEA STAFF APPLICATION FORM

PERSONAL PROFILE :

Name SAMSUDIN
Position Applied ENGINEER OFFICER CLASS ATT III
Date of Birth 08 AUGUST 1969
Place of Birth JAKARTA
Age 51 YEARS
Religion MOSLEM
Nationality INDONESIA
Marital Status MARRIED
Blood Group B
Home Address DESA PINTU RT. 001/001 NO.66 KEL.PATRASANA KEC. KRESEK KAB. TANGERANG -
BANTEN
Nearest Airport JAKARTA CENGKARENG AIRPORT
Weight(kg) 58 kg
Height(cm) 170 cm
Home Tel +6281297602226
Email Address Samsudin2387@gmail.com
Skype SAMSUDIN 123
Mother Name RUMSA
Vessel Type ANYTHING
Mobile No1 +6281297602226
Mobile No2
Availability Date ANYTIME I’M READY
Father Name BASO
Safety Shoes Size 41
Cover All Size XL
TRAVEL DOCUMENTS :

Description Document Number Country of Issue Issue Date Expiry Date

Passport C3505522 JAKARTA 02 MARCH 2020 02 MARCH 2025
Seaman Book E080513 JAKARTA 20 OCT 2020 02 MAY 2023
Seaman’s Book Panama P0201045 JAKARTA 19 SEPT 2019 10 DEC 2023

COMPETENCY CERTIFICATES :

Certificate Name Certificate Number Country of Issue Issue Date Expiry Date
Certificates Of Competency Class ATT III 6200032763530220 JAKARTA 22SEPT 2020 22 SEPT 2025
Endorsement Management ATT III 62000327635C0220 JAKARTA 29 SEPT 2025 29 SEPT 2025

NEXT OF KIN :

Name of Next of Kin : MASYANTI Relationship : WIFE

Residential Address DESA PINTU RT. 001/001 Email :
NO.66 KEL.PATRASANA KEC.
KRESEK KAB. TANGERANG -
BANTEN
Home Tel +6285784104252 Mobile No : +6281296809058

SCTW CERTIFICATES

Certificate Name Certificate No Place of Issue Issue Date Expiry Date

Basic Safety Traning (BST) 6200032763010117 JAKARTA 11 January 2017 11 January 2023
Advance Fire Fighting (AFF) 6200032763060118 JAKARTA 02 July 2018 02 July 2023
Proficiencyin Survival Craftand Rescue Boat 6200032763040118 JAKARTA 02 July 2018 02 July 2023
(SCRB)
Ship Security Officer (SSO) 6200032763240218 JAKARTA 13 August 2018 13 August 2023
Engine Room Resource Management (ERM) 6200032763270218 JAKARTA 10 August 2018 10 August 2023
Security Awarness Training (SAT) 6200032763310214 JAKARTA 15 January 2019 15 January 2023
Seafarers Designated Security Duty (SDSD) 6200032763320214 JAKARTA 28 October 2019 28 October 2023
Medical Firs Aid (MFA) 6200032763070218 JAKARTA 10 August 2018 10 August 2023
Medical Care On Board Ship (MC) 6200032763080218 JAKARTA 10 August 2018 10 August 2023
Basic Training For Oil And Chemical Tanker 6200032763390118 JAKARTA 16 July 2018 16 July 2023
Cargo Operation (BOCT)
Basic Training For Liquefed Gas Tanker Cargo 6200032763370118 JAKARTA 16 July 2018 16 July 2023
Operation (BLGT)
CCM Crowded Management 6200032763130218 JAKARTA 24 August 2018 24 August 2023
CCM Crisi Management 6200032763170218 JAKARTA 28 August 2018 28 August 2023
OFFSHORE CERTIFICATE :

Certificate Name Certificate No Place of Issue Issue Date Expiry Date

HUET(Opito) or BOSIET(Opito) 52515195060519316599 GTSC (UAE) 06 MAY 2019 05 MAY 2023
H2S (Opito) 52519014040519316175 GTSC (UAE) 04 MAY 2019 03 MAY 2021
H2S (Opito) 00589014250819181875 ETSDC(UAE) 25 AUG 2019 24 AUG 2021
ADMA - OPCO Induction ABU DHBI (UAE) 21 AUG 2014
Basic offshore Safety 21892/2014 ETSDC(UAE) 17 AUG 2014 16 AUG 2017
Advanced Fire Fighting 2194/2014 ETSDC(UAE) 18 AUG 2014 17 AUG 2017
Welding Safety B1664430 GTSC (UAE) 05 MAY 2019 04 MAY 2022
Martins (English Languange Test) 936CA19131F80BD8 JAKARTA 09 OCT 2020 Unlimited
Name Of Certificate LINK / GOOGLE Certificate Number Place Of Issue Date Expiry Date
T-BOSIET WWW.BRAVO7.CO.ID 0270-B7-004-02-102018 Jakarta, 17 OCT 2018 17 OCT 2022
BASIC OFFSHORE SAFETY WWW.BRAVO7.CO.ID 0001-B7-004-43-102018 Jakarta, 19 OCT 2018 19 OCT 2021

MEDICAL FITNESS CERTIFICATE :

Certificate Issue Date Expiry Date

Mefical Fitness Report (ILO Standard) April 17, 2019 April 17, 2020
Drug & Alcohol Test April 17, 2019 April 17, 2020

DECLARATION OF APPLICANT :

Answer Yes or No to the following questions. if Yes, give details below. Yes No
1 Has any previous dismissed you for misconduct? NO
2 Have you had any serious ilness, injury or operation affecting you work? NO
3 Do you have any physical handicap including eyesight or hearing? NO
4 Have you ever being convicted in a court of law in any country? NO
5 Can you swim? YES
 RECORD OF SEA SERVICE

Note : Latest Experience on Top :

Vessel Type Rank Company Area of Sign on Sign of Gt/Bhp Plag Type
Name Operation Date Date Engine
MV. WASSAY AHTS 2ND ENGINEER GSME (UAE) SAUDI 22-08-2020 28-07-2020 625 / 2X2537 Panama Caterpillar

MV. WASSAY AHTS 2ND ENGINEER GSME (UAE) ABU DHBI 03-05-2019 23-07-2019 625 / 2X2537 Panama Caterpillar

MV. GHAZI AHTS 2ND ENGINEER GSME (UAE) SAUDI 10-09-2017 10-11-2017 686 / 2X2800 Panama MAK

MV. RIZWAN AHTS 2ND ENGINEER GSME (UAE) SAUDI 03-02-2017 10-09-2017 686 / 2X2800 Panama MAK

MV. WASSAY AHTS 2ND ENGINEER GSME (UAE) ABU DHBI 18-08-2016 26-11-2016 696 / 2X3500 Panama Caterpillar

MV. AHTS 2ND ENGINEER GSME (UAE) SAUDI 15-05-2016 12-08-2016 696 / 2X3500 Panama Caterpillar
GHAZNAVI ARABIA
MV. HARRIS AHTS 2ND ENGINEER GSME (UAE) ABU DHBI 07-05-2015 12-24-2016 696 / 2X3500 Panama Caterpillar

MV. JABAR AHTS 2ND ENGINEER GSME (UAE) ABU DHBI 03-052014 27-04-2015 625 / 2X2500 Panama Caterpillar

MV. BABBER AHTS 2ND ENGINEER GSME (UAE) SAUDI 25-05-2011 02-05-2012 696 / 2X3500 Panama Caterpillar
ARABIA
MV. BABBER AHTS 2ND ENGINEER GSME (UAE) ABU DHBI 21-10-2010 12-04-2011 696 / 2X3500 Panama Caterpillar

MV. WASSAY AHTS 2ND ENGINEER GSME (UAE) ABU DHBI 04-09-2009 17-08-2010 625 / 2X2500 Panama Caterpillar

TB. KUDA ASD TUG C/E DARSA JAYA INDONESIA 02-01-2001 16-01-2002 410 / 2X1000 INDONESIA YANMAR
LAUT
TB. KURNIA ASD TUG C/E DARSA JAYA INDONESIA 27-07-1999 07-11-2000 452 / 2X1250 INDONESIA YANMAR

TB. KUNCUP ASD TUG 1ST ENGINEER BINA MALAYSIA 21-06-1998 01-07-1999 546 / 2X1750 MALAYSIA YANMAR
TUNAS ARMADA
TB. MITRA ASD TUG 1ST ENGINEER BINA MALAYSIA 07-04-1997 21-04-1998 520 / 2X1700 MALAYSIA YANMAR
ARMADA

I Hope that my application can be accepted, called and interviewed anytime at any time and i will try to work
well, look after and care for the ones you trust in me from the company you lead

Sincerely yours

( SAMSUDIN )