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APPLICATION FORM

Personal Data

Name Muhammmad Ilham Religion Moslem


Next of kin - Status Married
Place of Birth Belawan Date 05.10.1992
Height 165 cm Weight 68cm
Waist 36 cm Shoes 41 cm
Home Address Phone - Mobile Phone 082286501578

Document Data
Passport C 067280 Date of Expiry 23.07.2018/23.07.2023
Seaman’s Book C 067280 Date of Expiry 12.08.12/11.08.2017

Certificate Of Competence
Marine Lisence Place of Issue Date of issue No.
Rattings as asble seafarers
Jakarta 15.05.2018 6200218321340218
deck
Endorsement certificate for
Jakarta 03.07.2018 620092000197395
officers and rattings

Certificate Of Proficiency
Course Title Number Issue Year Issued at
Basic Safety Training (BST) 6200218321010718 25-06-2018 Jakarta
Survival Craft and Rescue Boat (SCRB) 6200218321040115 05-10-2015 Jakarta
Advanced Fire Fighting (AFF) 6200218321010115 05-10-2015 Jakarta
Medical First Aid (MFA) 6200218321070718 15-07-2015 Jakarta
Security Awareness Training (SAT) 6200218321310718 04-07-2018 Jakarta
Basic Training For Oil And Chemical
62002183211390118 30-05-2018 Jakarta
Tanker Cargo Operations
Seafarers With Designated Security
6200218321320118 25-05-2018 Jakarta
Duties (SDSD)

No Name Of Vessel Company Rank Vessel Type Service Periode


1. TK.DEWI 2 INDONESIA A/B Tongkang 02.02.2014/24.08.2015
2. BG.CAROLINE 2 INDONESIA A/B Tongkang 17.12.2014/24.06.2015
3. TB.PPKR.9 INDONESIA A/B TUG Boat 17.03.2016/03.06.2016
4. MT.PERLA INDONESIA A/B Tanker 15.08.2016/13.03.2018
5. MT.PERLA INDONESIA A/B Tanker 27.07.2018/14.06.2019
6. TB.DELTA CAKRA INDONESIA A/B Tug boat 18.10.2019/06.09.2020
SPOB ANUGERAH A/B
7. INDONESIA SPOB 07.10.2020/05.11.2021
BERSAMA 7
Record Of Sea Service

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