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Crew No:
2941
FORM DATA PRIBADI 0
APPLICANT INFORMATION FORM
MSM-FRM-CRW.02.05
Rev.0 (01/12/2018) Contract Start: Insert foto here

RSO:
Date : 6/Apr/22 Crew No.: 2941
1 Rank Applied For : Date of Availability: 6/Apr/22
PERSONAL DESCRIPTION AND INFORMATION
2 Name First: FATHOR Middle: Last: ROSI
3 Birth Date: 17/Sep/89 Place : BANGKALAN Nationality: INDONESIA
4 NIK Number: 3526121709890001 Sex: MALE Religion: ISLAM NPWP: 35.217.226.6-644.000
5 Bank Name 1: Bank Mandiri Branch: KCP SURABAYA KEMBANG JEPON Bank Account 1: 1400007430375
6 Bank Name 2: Bank Mandiri Branch: Bank Account 2:
7 Passport No: C2480976 Place of Issue: KENDARI Date of Issue: 9/Jan/19 Date of Expiry: 9/Jan/24 Issuing Country: INDONESIA
8 Seaman Book No: H002944 Place of Issue: SURABAYA Date of Issue: 27/Jan/22 Date of Expiry: 27/Jan/25 Issuing Country: INDONESIA
9 Permanent Address: DS.KESEK KMP.TENGGINAH RT.00 RW.00 KEC.LABANG Zip:
10 State/ Province: JAWA TIMUR City: BANGKALAN Email: fathorrossi055@gmail.com
11 Home Phone No.: Mobile 1: 81232649887 Mobile 2: Whatsapp: 81232649887
12 Marital Status: MARRIED No. of Children: 1 Nearest Airport/ Station: BANDARA JUANDA SURABAYA
Emergency Contact
13 Family/NOK/Emergency Contact Relation Date of Birth Place of Birth Passport No. Date of Issue Date of Expiry Place of Issue NOK
Number
SISCKA DEWI SURYATININGSIH SPOUSE 3/24/1993 BLORA 085602666855

Name: TUTIK NURYATI NINGSIH Relationship: SIBLING Mobile: 085104017700

Next of Kin - [ Name , Address & Contact
14 Address: DS. KESEK RT.00 RW.00 KEC.LABANG
Details] - In case of Emergency
State/ Province: JAWA TIMUR City: BANGKALAN Email:

15 Licenses/ Certificates/ Endorsement Certificate Number Date of Issue Date of Expiry Issuing Body Country

BASIC SAFETY TRAINING 6200358600010520 18/Sep/20 18/Sep/25 POLTEKPEL SURABAYA INDONESIA

MEDICAL FIRST AID 6200358600070515 25/Nov/15 POLTEKPEL SURABAYA INDONESIA
ADVANCED FIRE FIGHTING 6200358600060520 28/Sep/20 28/Sep/25 POLTEKPEL SURABAYA INDONESIA
SECURITY AWARENESS TRAINING 6200358600310515 16/Oct/15 POLTEKPEL SURABAYA INDONESIA
SEAFARERS WITH DESIGNATED SECURITY DUTIES 6200358600320515 12/Nov/15 POLTEKPEL SURABAYA INDONESIA
PROFICIENCY IN SURVIVAL CRAFT AND RESCUE BOATS 6200358600040520 18/Sep/20 18/Sep/25 POLTEKPEL SURABAYA INDONESIA
RATINGS AS ABLE SEAFARER DECK 6200358600340520 19/Nov/20 POLTEKPEL SURABAYA INDONESIA

16 Courses/ Trainings Certificate Number Date of Issue Date of Expiry Issuing Body Country

PREVIOUS SEA EXP. [ Datewise up to 25 previous vessels in ascending order ] ie : End with your last vessel served
Manning Agents/
17 Vessel Name IMO No. Type Flag Engine & Type Rank From To Experience
Employer
KM Mentaya River Container INDONESIA PT MERATUS LINE Ordinary Sailor 24/Apr/09 24/Sep/10 518 1 years 5 months 1 days
KM Meratus Ultima I Container INDONESIA PT MERATUS LINE Able Body 10/Nov/10 11/Jan/11 62 0 years 2 months 2 days
KM Meratus Medan 3 Container INDONESIA PT MERATUS LINE Able Body 8/Jul/11 12/Jan/12 188 0 years 6 months 6 days
KM Meratus Mamiri Container INDONESIA PT MERATUS LINE Able Body 23/Apr/12 18/Jul/12 86 0 years 2 months 26 days
KM Meratus Kalabahi Container INDONESIA PT MERATUS LINE Able Body 28/Apr/14 1/Aug/15 460 1 years 3 months 4 days
KM Meratus Pekanbaru Container INDONESIA PT MERATUS LINE Able Body 27/Feb/16 10/Jun/16 104 0 years 3 months 13 days
KM Teritory Trader Container INDONESIA PT MERATUS LINE Able Body 28/Jul/16 18/Jan/18 539 1 years 5 months 22 days
KM MERATUS Labuan Bajo Container INDONESIA PT MERATUS LINE Able Body 9/Apr/18 9/Mar/19 334 0 years 10 months 29 days
KM MERATUS Dili Container INDONESIA PT MERATUS LINE Able Body 29/May/19 29/Jul/20 427 1 years 2 months 2 days
KM MERATUS Payakumbuh Container INDONESIA PT MERATUS LINE Able Body 29/Oct/20 12/Jan/21 75 0 years 2 months 15 days
KM MERATUS Payakumbuh Container INDONESIA PT MERATUS LINE Bosun 9/Feb/21 27/Dec/21 321 0 years 10 months 16 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
0 0 years 0 months 0 days
SUMMARY OF KNOWLEDGE AND EXPERIENCE ACQUIRED [Give a brief resume of your Career and Experience at Sea, e.g. Type of Ships, Engines, Specific Trades (E.G. ICE / Lighterage etc.),
18
reactivation, New Buildings, Shore Experience, Computer Knowledge etc.]

19 Name of Schools / Colleges Attended City / Country From To Type of Degree / Diploma / Qualification Received

REFERENCES:
20 Title Name Company Name Phone Number Email

LANGUAGES
21 LANGUAGE Spoken Written Read OTHER [specify] Spoken Written Read
ENGLISH GOOD GOOD GOOD

PHYSICAL DECLARATION
With Glasses: Colour Blind: NO
22 VISION
Without Glasses:
Height (cms) 170 Hair [colour] BLACK Blood Group: O
23
Weight (kgs) 72 Eyes [colour] BLACK Identification Mark on body [if any]:
24 Wearpack Size L Shirt L Trouser
ADDITIONAL INFORMATION
25 Are you involved in any marine accident/investigations? [Collision/Grounding/Fire/Pollution]? If yes please give details
No, I'am not.

26 Did you suffer any accident which rendered you temporarily and / or partially disabled ? If yes please give details.
No, I didn't

27 Are you currently under medical treatment or taking medication for existing conditions? If yes please give details
No, I'am not

28 Did you suffer , or do you presently suffer from any diseases likely to render you unfit for sea service or likely to endager the health of other persons onboard ?
No, I don't

29 Did you ever undergo psychiatric treatment ?

No, I didn't

30 Are you addicted or using alcohol or drugs of any kind ?

No, I'am not

REASON FOR LEAVING LAST EMPLOYER

1
31
2
CONTACTS OF SENIOR OFFICERS SAILED WITH FOR REFERENCE CHECK (NAME & PHONE NUMBER)
Name Last Rank Phone Number Other Information
1
32
2
3
HOW DID YOU COME TO KNOW ABOUT US? (Please tick the appropriate medium)
A Company presentation/seminar/website D Seafarer forum/ community F Marine magazine advertisement
33 B Newspaper advertisement E Told by seagoing friend(s) G Direct Mail from Company
C Others (Please specify)
DECLARATION
I certify that the details given by me in filling up this form are true, complete, and correct to best of my knowledge and belief. I understand that any misrepresentation or material omission made in this application form or other
documents submitted to Meratus Line may renders me liable for termination or dismissal.

Date: 6/Apr/22 SIGNATURE OF APPLICANT

Please hand in, mail or e-mail your application to: msm.recruitment@meratusline.com

PT. Meratus Line PT. Meratus Line
Head Office Branch Office
Jl. Aloon-aloon Priok No.27 Jl. Raya Enggano No. 5N-5O
Surabaya - Indonesia Tanjung Priok - Jakarta - Indonesia
Tel: +62 31 3292288, 3294488 Tel: +62 21 4307790
Fax: +62 31 3299047 Fax: +62 21 4366827