Application Form FOTO

FOPosition Applied For :

1. Personal Details
First Name Last Name

Current Address City : Province / State : West Nusa Tenggara

Postal Code : Country : Indonesia

Date of Birth Place of Birth

Age Nationality REPUBLIK INDONESIA

Gender Marital Status

Height Weight

Contact No.

Email Address

2. Education Background
No. Level School Commence Completed

1. Jnr. High School 

2. Snr. High School 
3. University / College

3. Employment History (Sea Service)

No. Vessel / Company Vessel Type Position From To

1. Job Scope:

2.
Job Scope:

4. Employment History (Land)

No. Company Name Hotel / Restaurant Position From To

1.
Job Scope:
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 2. Job Scope:

Job Scope:
3.

Job Scope:
4.

5. Documentations
No. Type Document Number Place of Issue Date of Issue Expiry

1. Passport

2. Seaman Book

3. Yellow Fever

4. US C1/D Visa

6. Certificates of Proficiency (STCW95)

No. Certificate Document Number Place of Issue Issue Date

1. Basic Safety Training (BST)

2. Crowd Management

3. Crisis Management

4. Survival Craft Rescue Boat

5. Security Awareness

7. Next of Kin
Name Relationship :

Address City : Province :

Postal Code : Country :

Contact No. Email :

I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge

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Date : Signature :

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AMPHITRITE PTE. LTD. Ship Manning and Management
ANNEX – Certificates / References

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AMPHITRITE PTE. LTD. Ship Manning and Management