JIE SHENG SHIP MANAGEMENT LIMITED

SEAFARER APPLICATION FORM (01/08/2021) C-06

Position Applied 申请职务

4th/Emgginer

Application Date 申请日期 For Vessel 申请船舶

Available Date 预计到职日 Manning Agent 船员代理

Recent
H&E

PERSONAL PARTICULARS 个人资料

Last Name 姓氏 Given Name (as in passport) 名(同护照) Chinese Name 中文名

Alfin Amirullah Alfin Amirullah

Phone No. 电话号码 Mobile No. 手机号码 Height 身高 Weight 体重 Overall 工作服 Safety Shoes 安全

082302302359 082302302359 169 cm 65 kg L 鞋

42

Place of Birth 出生地 Date of Birth 出生日期(DD/MM/YYYY) Nationality 国籍 Blood Type 血型 Hair Color 发色 Eyes Color 瞳色

May 17th 1998 May 17th 1998 Indonesia A+ Black Black

ID No. 身分证号 Marital Status 婚姻状态 Religion 宗教 Medical History 病史

6211750635 Unmarried Moeslim

Address 目前家庭住址 Email 个人电邮

Desa. Lamunre, Kec. Belopa Utara, Kab. Luwu, South Sulawesi Selatan alfinamirullah98@gmail.com

Indonesia

HIGHEST ACADEMIC QUALIFICAITION 毕业/培训学校

From 从(DD/MM/YYYY) To 至(DD/MM/YYYY) Institutions/Universities attached 机构/学校名 Qualifications 程度

23/09/2016 19/12/2020 Politehnik Maritim Ami Makassar B

FAMILY BACKGROUND 家庭背景

Next of Kin 直系亲属姓名 Relationship 关系 Phone No. 家属电话

Jumaiya Biological Mother 082187598601

Address of Next of Kin 家属住址

Desa. Lamunre, Kec. Belopa Utara, Kab. Luwu, South Sulawesi Selatan Indonesia

IMMIGRATION DOCUMENTS 申请出入境文件

Passport 护照 Issued at 签发单位 Issued Date 发行日(DD/MM/YYYY) Expiry Date 到期日(DD/MM/YYYY)
 JIE SHENG SHIP MANAGEMENT LIMITED
SEAFARER APPLICATION FORM (01/08/2021) C-06

C 0812890 Makassar 14/08/2018 14/08/2023

Seaman Book No. 海员证 Issued at 签发单位 Issued Date 发行日(DD/MM/YYYY) Expiry Date 到期日(DD/MM/YYYY)

F 168961 Makassar 10/10/2018 10/10/2023

USA Visa 美国签证 Issued at 签发单位 Issued Date 发行日(DD/MM/YYYY) Expiry Date 到期日(DD/MM/YYYY)

DETAILS OF PREVIOUS SEA SERVICE 详细的海上经历

Period of Service 期 Reason
Flag of Type of Main Name of
Rank Name of Vessel GRT HP 间(DD/MM/YYYY) for sign-
Vessel Vessel Engine Company
职务 船名 吨位 马力 Duration off 下船
船国籍 船型 主机型号 Sign-On Sign-Off 服务公司
(mth) 原因

Engine KM. ADITHYA INDONE PASSAN KOBE 3778 GT 3600x2 08 Dec 24 Jan 2020 01 Finish PT. Afta Trans

Cadett SIA GER DIESEL kW 2018 year, Contrack Mandiri

LOCAL MITSUB 01

SHIP ISHI month,

16

days

4th Eng RATU INDONE OIL MAN B 23,246 15,050 08 Otc 12 Apr 06 Finish PT. Barokah

RUWAIDAH SIA TANKE &W GT kW 2020 2021 month, Contrack Gemilang Perkasa

R 4 days

4th Eng HIPPO INDONE OIL SULZER 29,111 11,845 20 Apr 23 Sep 05 REVALI PT. WARUNA

SIA TANKE 6RTA52 GT kW 2021 2021 month, DASI SENTANA

R U 3 days SERTIFI

KAT
 Issued Date Expiry Date
Qualification Cert No. Issued By
发行日 发行日
资格证书 证书号码 发行单位
(DD/MM/YYYY) (DD/MM/YYYY)

Certificate Of Competency
RANK: 4th/Engginer GRADE: III

National Certificate of Competency (For Officer) 6211750635T30420 08 Sep 2020 Unlimited Jakarta

GMDSS(For Deck Officer) - - - -

National Certificate of Endorsement(For Indonesia Officer) 6211750635TC0420 08 Sep 2020 08 Sep 2025 Jakarta

Watch Keeping Certificate(For Rating/Others) - - - -

Certificate Of Proficiency
Basic Training 6211750635010417 26 Sep 2017 26 Sep 2022 Makassar

Security Awareness Training 6211750635310418 27 July 2018 27 July 2023 Makassar

Seafarers With Designated Security Duties - - - -

Basic Training For Oil and Chemical Tanker Cargo Operation 6211750635390418 02 Oct 2018 02 Oct 2023 Makassar

Proficiency In Survival Craft and Rescue Boat Other Than Fast Rescue Boats 6211750635040420 26 Aug 2020 26 Aug 2025 Makassar

Training In Medical First Aid 6211750635070418 07 Aug 2018 07 Aug 2023 Makassar

Training In Advanced Fire Fighting 6211750635060418 10 Aug 2018 10 Aug 2023 Makassar

Training In Medical Care 6211750635080420 25 Sep 2020 25 Sep 2025 Makassar

Proficiency For Ship Security Officer 6211750635240420 29 Sep 2020 29 Sep 2025 Makassar

Advanced Training For Oil Tanker Cargo Operation 6211750635410420 05 Oct 2020 05 Oct 2025 Jakarta

Advanced Training For Chemical Tanker Cargo Operation 6211750635400421 Proccess

ECDIS - - - -

BTM/ ERM 6211750635275520 9 Apr 2020 09 Apr 2025 Makassar

Medical Documents
Certificate Of Health Examination(one year)(For China crew) - - - -

Medical Certificate For Seafarers(two years) - - - -

The American Club Pre-employment Medical Examination(For Indo. Crew) - - - -

Cholera Vaccine Certificate - - - -

Yellow Fever Vaccine Certificate H00-376444 29 Nov 2018 Unlimited Makassar

Flag State Certificate

PANAMA MARSHALL KIRIBATI NAURU Other：
Expiry Date Expiry Date Expiry Date Expiry Date

(DD/MM/YYYY) (DD/MM/YYYY) (DD/MM/YYYY) (DD/MM/YYYY)

COE

GOE

OT

SDSD/SSO

Reference Check by JIE SHENG crew manager:

Declaration to be signed by the Applicant

I hereby certify that the information contained in this form is completed & correct. I understand that the Company may
terminate my service at any time if any of the above information is found to be false.
 JIE SHENG SHIP MANAGEMENT LIMITED
SEAFARER APPLICATION FORM (01/08/2021) C-06

Signature of Applicant/Date 24 September 2021

For Office：
No Interview Content Result(Y/N) Comment

1 Language Ability

2 Professional Capability

3 Personal Characteristics

Interview by/Date: ________________________/___________Department:____________Status: Approved / Rejected