Quality through

Excellence

Seafarers Application Form ASL Form

No. CRW006

Present Rank:. Rank applied for:

Oiler Oiler

Name in full: Hasbi Abidin

Father’s name : Abidin Mother’s name :

Nurhaeda
Date/Place of birth : Palopo, 11 April 1985 Nationality: Indonesia

Address: Jl. Tumbu Bara RT.002/001 Kel. Tumbu Barak Kec. Bajo Barat
Kab. Luwu
Phone: +62 81217829878
Next of kin / Relationship / Address: Jl. F Gg.K No.13 RT.003/005 Kel. Rawa
Badak Utara Kec. Koja, Jakarta Utara

Height: 155 cm Weight: 55 Kg

Marital status: Married Suit size: M Shoe size: 40

No. of Children: -

Last medical Yellow fever U.S Visa Date of availability:

examination date: vaccination date: expiry date: -
March 2021

CONTROLLED Revision: 01 Dec 2020

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 Quality through
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Seafarers Application Form ASL Form

No. CRW006

DOCUMENTS No Issued Expire Country Issue

License National

License Other

Seaman Book Nat. F 160336 26 Sept 2023 26 Sept 2025 Jakarta

Seaman Book Other

Passport C 6583840 28 Sept 2021 28 Sept 2026 Citizenship : Indonesia

ENGLISH: GOOD AVERAGE POOR Suggestions:

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Excellence

Seafarers Application Form ASL Form

No. CRW006

CERTIFICATES DOCUMENTS NO. / DATE OF EXPIRE TRAINING BY COP TESDA

ISSUE
Certificate of Competency /Ratings 6201288438420716 13 Feb 2028
/ 13 Feb 2023
MLC – F1
MLC – F2
MLC – F3
MLC – F4
General Tanker Certificate / (BTOC) 6201288438390122 02 Nov 2027
/ 02 Nov 2022
Shore Base Fire Fighting
Proficiency in Survival Craft & Rescue 6201288438041120 21 July 2025
Boat / 21 July 2020
Basic Safety Training / (Basic Training) 6201288438011120 11 July 2025
/ 11 July 2020
Advanced Fire Fighting 6201288438061120 22 July 2025
/ 22 July 2020
Specialized Oil Tanker Certificate /
(ATOT)
Specialized Chemical Tanker
Certificate /(ATCT)
Specialized Liquified Gas Tanker
Certificate /(ALGT)
Consolidated Marpol 73/78
(I,II,III,IV,V,VI)
Ship Security Officer 2012
Ship Security Awareness Training & 6201288438311123 15 Feb 2028
Seafarer with Designated Security / 15 Feb 2023
Duties (SSATSDSD) 6201288438321115 29 Sept 2020
/ 29 Sept 2015
DECK OFFICERS CERTIFICATES
Ship Safety Officer / Shipboard Safety
Officer
Ship Handling & Maneuvering
SSBT
Bridge Resource Management
Bridge Team Management
ECDIS (Generic)
ECDIS (Specific)
Type Specific if any
Global Maritime Distress and safety
System
INMARSAT
Ship Restricted Radio Operator Course
RNRP(U)A (ROC/RSC/ARPA)
Medical First Aid 6201288438070115 17 Sept 2020
/ 17 Sept 2015
Medical Care
Deck Watch keeping

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Seafarers Application Form ASL Form

No. CRW006

ENGINE OFFICERS CERTIFICATES

Engine Room Simulator Course
Engine Resource Management
Auxiliary & Machinery System
Hydraulics & Pneumatics
Control Engineering
Engine Watch keeping
CATERING PERSONNEL CERTIFICATES
Culinary & Catering Course /Catering
Management
International Culinary
Baking
Bread Making
House keeping
Health & hygienic
Messman Course / Basic Shipboard
Food Service
OTHER CERTIFICATES
Crude Oil Washing Inert Gas
Dangerous Hazardous & Harmful
Cargoes
International Safety Management
Maritime English for Officers
Risk Assessment
Incident Investigation
Maritime Law
Maritime English for Ratings
Shipboard Environmental
Management
Voyage Data Recorder
Integrated Bridge System
Shield Metal, ARC & GAS Welding
Padams
Framo Pumps
CES Certificate with score
Anti-Piracy Awareness Training
Seminar
PDOS
MLC 2006

Previous Services:

SHIP’S FLAG AGENCY / GRT/ SHIP ENGINE DATE DATE PERIOD REASON OF
PERIOD
NAME/ COMPANY BHP TYPE TYPE SIGN-ON SIGN.OF RANK ONBOARD LEAVING/
ASHORE IN
YEAR OF F MONTHS PORT
DAY/MO./ MONTHS
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 Quality through
Excellence

Seafarers Application Form ASL Form

No. CRW006

BUILT/ YR. DAY/MO./YR

IMO
NUMBER

MV. Intan Indonesia PT. AMN 1995/ 1545Cargo Guangz 06.12.2010 25.12.2011 Oiler 12 Month 2 Month Finish Contract
Daya 5 hou
Guangc
hai
TB. MKM Indonesia PT. Bintang 135/ Tug Mitsubis 10.02.2012 03.08.2013 Oiler 12 Month 12 Month Finish Contract
1501 Arwana 2x850 Boat hi

TB. Bahar Indonesia PT. Habco 209/ Tug Caterpill 14.09.2014 02.01.2016 Oiler 24 Month 1 Month Finish Contract
97 Primatama 2x537 Boat ar

TB. Indonesia PT. Tonico 203/ 2x600Tug Yanmar 20.02.2016 27.05.2017 Oiler 12 Month 4 Month Finish Contract
Kapuas Ekamarindo Boat
Bahari XIX

MT. Amas Indonesia PT.Amas 2730/ 2800Tanker Hanshin 25.09.2017 26.10.2018 Oiler 12 Month 8 Month Finish Contract
Nusa Nusa Diesel
Persada

MT. Damai Indonesia PT. MMI 2765/ Tanker Nigata 20.06.2019 14.07.2020 Oiler 12 Month 8 Month Finish Contract
Sejahtera 8 763

MT. Krasak Indonesia PT. 5256/ 3500Tanker Hanshin 09.03.2021 12.09.2021 Oiler 6 Month 2 Month Finish Contract
Pertamina Diesel

MT. Kuang Indonesia PT. 5263/ 3500Tanker Nigata 03.11.2021 10.03.2022 Oiler 5 Month 1 Month Finish Contract
Pertamina

MT. Indonesia PT. 2938 / 1620

Tanker Yanmar 28.03.2022 23.09.2022 Oiler 6 Month 3 Month Finish Contract
Mauhau Pertamina

MT. Indonesia PT. 2621/ 2000Tanker Nigata 05.12.2022 28.01.2023 Oiler 2 Month 10 Month Finish Contract
Mangun Pertamina
Jaya

APPLICANT SIGNATURE DATE

(NAME): 07-11-2023
HASBI ABIDIN

CREW MANAGER APPLICATION REVIEW (application’s validity to be reviewed prior each employment)

CONTROLLED Revision: 01 Dec 2020

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 Quality through
Excellence

Seafarers Application Form ASL Form

No. CRW006

NAME DATE SIGNATURE

INTERVIEW FORM (As per attached interview check list)

ONLY for the accepted applicants. Interview will be carried out by the Department Managers or their deputies.

SEAFARER’S NAME: RANK: INTERVIEW

DATE:
HASBI ABIDIN OILER 07-11-2023

CERTIFICATES’ AUTHENTICITY CHECK Completed by the Crew Manager, when recruitment is conducted directly
by the Company.
Completed by the Manning Agent, when the recruitment is conducted by the Manning Agency and verified by the Crew
Manager.
Authenticity check conducted for certificates:

CONDUCTED BY MANNING AGENT (Name/Position)

DATE RESULTS Satisfactory Unsatisfactory
VERIFIED BY CREW MANAGER (Name)
DATE RESULTS Satisfactory Unsatisfactory

REFERENCES/INFORMATION, ETC. FROM PREVIOUS EMPLOYERS (to be completed by Crew Manager/Manning

agent)

MEDICAL EXAMINATIONS TO BE CONDUCTED PRIOR TO SEAFARER’S ENGAGEMENT

MEDICAL EXAMINATIONS AND D&A TEST COMPLETED SATISFACTORY? YES NO

CONTROLLED Revision: 01 Dec 2020

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