3.

01 – Crew Application Form including Crew Author: DPA

Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

*Part 1 – Crew Application Form

A. Personal Particulars
Name in Chinese Paste Photo Here
Name in English Nazarta
(if available)
Place of birth Kolaka Date of birth 16-11-1996
Nationality Indonesia Native district Jakarta
Date Issue & 29-08-2023 &
Seaman’s Book I 1071990
Expiry 29-08-2026
Passport No. Date Issue & 25-08-2023 &
(Validity MUST be E 4319587 25-08-2033
Expiry
minimum 6 months)
R 4114966 Date Issue & 03-02-2022 &
US VISA
Expiry 01-01-2026
Date Issue & KARKO English*
Schengen Visa
Expiry
Rank applied for Nearest Airport KARCO score
Male Shoe size 40 Marlin Test & 82
Sex Weight 60
Score * if any
21.2 Boiler suit M INDOS No (ind)
BMI Height 170
size
Crew Agent . Address
& PIC contact details
Applicant Address: Tel:

Applicant Email Mobile: +6285772360369

nazarzarta@gmail.com
address:
Have you been rejected for any visa applied for? (if yes full detail) Y/N N
* for Chinese Officers and Chinese deck ratings

B. Family status
Relation Name Date of birth Occupation Address / telephone
Father La faruli 01-01-1964 JL dayanu ikhsanuddin
Mother Nur aminah 25-10-1970 JL dayanu ikhsanuddin

B1. Next of Kin

(Name, Address & Contact Numbers)

C. Academic Education
School SMAN 3 Baubau
University Academy maritime jadayat
Apprenticeship/
Nautical
Marine College

Page 1 of 10
 3.01 – Crew Application Form including Crew Author: DPA
Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

Type of
Certificate COC Class 3
obtained

D. Maritime Certificate Held (National/ Flag)

Certificate National Panam Hong Marshall Liberia Other Endorsement
of a Kong (Oil/Gas/Chem)
Competenc
y
License 621157090901012
Number 1

Grade/ STCW
Regulation

Issue 26-10-2023

Expiry 26-10-2028

Mandatory No/Date Certificate No/Date Certificate No/Date

STCW
Courses
(Deck &
Engine)
Basic Safety 6211570909010121 Fire-fighting 621157090906012 Medical First 621157090907011
Training (Basic/ 1 Aid /Medical 6
(BST) Advanced) care
ROC / ARPA 6211570909020218 PSCRB 621157090904012 PSSR
1
Incident GMDSS / GOC 6211570909G1011 Fast Rescue
Investigatio 9 boat
n
Tanker Tanker Safety Tanker Safety
Safety (OTFC/ Gas
Chemical TASCO) (Basic/Advance
Basic/Adv d)
Security 6211570909320121 Safety Officer Ship Security 621157090924011
Awareness Course Officer 8
Training
Course
BRM 6211570909230219 BTM MRM/ERM
ECDIS (Type 6211570909280218 ECDIS D.C.E. V/1,V/2,
Specific) (Generic) V/3
Crowd & 6211570909170120 Cyber Security ME training (for
Crisis awareness engineers)
Managemen
t
Ship
Handling
Simuator
Specialized Courses / Other offshore course(s) / Industries’ / Charterer requirements

Page 2 of 10
 3.01 – Crew Application Form including Crew Author: DPA
Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

Ship Working at
DP Course –
Maneuvering Height
Basic
and Bridge
Induction
Team Work
DP Course - Engine Rigging / Slinging
Advance Simulator and Lifting course
Risk English
DP
Assessment Proficiency /
Maintenance
Marlin Test
Huet Efficient Deck Navigation
Hand Control Course
Bosiet Electronic
Navigation
System

Record Of Previous Sea Service

** List all vessels starting from the last vessel until first vessel
Vessel Ship Type GT / DWT / En HP Owner Rank Sign-on Sign-off
(Oil/LPG/L DP Type gin

Months
NG/Bulk/ e

Days
Container Ty
/ Others) pe
MV Sinopa Cargo 1748 Dies 3000 PT cadet 10-05- 25-05-
el nusantar 2017 2018
a bahari
jaya
sentosa
MV Amber AHTS 1120 3000 BNI 3rd 10-07- 16-01-
Yan officer 2018 2019
mar
MV Osam AHTS 950 Yan 3000 BNI 3rd 05-02- 20-07-
daisy mar officer 2019 2019
TB Royal Tugboat 140 dies 3000 PT Chief 07-08- 07-
palma el Delimud officer 2020 03=2021
a
nusantar
a
Symphony Cruise ship 230.000 War 27.000 RCL Junior 19-02- 15-10-
ots tsila seam 2022 2022
an
Symphony Cruise ship 230.000 War 27.000 RCL Junior 10-12- 06-08-
ots tsila seam 2022 2023
an

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 3.01 – Crew Application Form including Crew Author: DPA
Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

Brief description of types of operations and operations locations.

(Input additional supporting information in the box below)

Vessel Name with DP operation (yes / no)

Additional Information:

Shore-based experience details (if any) :

A Cargoes
carried
B Trading
pattern
C Nationaliti
es sailed
with
D Cargo
gears
E Computer
skills
F Miscellane
ous
G Years in Rank

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 3.01 – Crew Application Form including Crew Author: DPA
Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

Years in THIS type of Tanker CHEM OIL LPG LNG gA

Years in ALL type of Tankers

Years in Watchkeeping

Year on other type ships Bulk Container Passenger Offshore

Reason for leaving last employer

a Finish Contract
b
Why you want to join IMM
I want to get new experience

E. Medical Certificate
Type Number Issuing Country Issue Date Expiry Date
Medical 0317/PEME-DA/PRI/X/2023 Indonesia 10-10-2023 08-10-2025
Drug & Alcohol Test 2170/D&A/PRI/X/ Indonesia 10-10-2023 08-10-2025
2023
Yellow Fever L00-0913560 Indonesia Life time Life time
Vaccination
Cholera Vaccination
COVID Vaccination
completed
Typhoid Vaccination

F. Medical and General History

Have you ever been signed Off a ship due to medical reasons? (if yes details)
Have you undergone an surgical operation in the past (if yes details)?
Have you consulted a doctor during last 12 months for an illness/Accident?
Do you have any health or disability Problem?
Have you been subject of a court of enquiry or involved in a maritime accident?
Have you ever had a professional license suspended or revoked?
Are you colour blind or partially deaf?
Do you take any medication regularly and depended on medicine?
Are you declared bankrupt?
Are you under any “bond” or under obligation to serve the Government or any other body?
Does your current employer know that you are thinking of leaving?
Highlights any Achievement attained during your career so far.
This section to be used for all above items with “yes” response in brief

G. BANK DETAILS:

Telegraphic Transfer

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 3.01 – Crew Application Form including Crew Author: DPA
Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

Beneficiary Name : Nazarta IBAN Account No. : 0832992000

IMPORTANT: address must translate exactly as in googlemaps.com

Address of beneficiary Beneficiary Bank : BNI
Street: JL Dayanu ikhsanuddin
House number: 07 Address : JL jenderal sudirman no.2
(Including City & Postal
Flat number (if any): Code) Baubau & 93711
Postcode: 93711
City Baubau
Country: Indonesia Country : Indonesia
SWIFT Code: : BNINIDJA
IBAN No. ( If any) :

Intermediary Bank (USD Currency Agent)

Bank Name : SWIFT Code: :
Clearing Code ( If any) :
Address :

IMPORTANT: full address including street, house number, flat number, postcode, city is required. Street name must exactly be
the same wording as in googlemaps.com service. Bank account number in IBAN format (for etc . starting from “UA”) as
Ukraine has entered IBAN system in January 2020 .

H. Declaration
I HEREBY DECLARE THAT ALL THE ABOVE PARTICULARS ARE TRUE AND AUTHORISE YOU TO CONTACT REFERENCES ABOVE. IF
EMPLOYED , IN THE EVENT OF A DISCOVERY OR ANY MISREPRESENTATION OF ACTS , WILFUL OR OTHERWISE I WILL BE
SUBJECTED TO SUMMARY DISMISSAL

I understand that my personal data will only be processed for the recruitment purposes and will only be
shared externally where it achieves those purposes, for example, by passing it to competent public
authorities where it is necessary to comply with a legal or regulatory obligation. The Company (IMM) may also
share my personal data with third party agents, service providers or subcontractors where this is necessary
to fulfil the purposes for which the data was collected (for example, to administer payroll or employment
benefits), or so The Company (IMM) can comply with their obligations or exercise their rights as my employer.

Page 6 of 10
 3.01 – Crew Application Form including Crew Author: DPA
Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

Nazarta 10-11-2023
Signature of the seafarer Date

**Part 2 – Crew Interview & Pre-Employment Checklist – Manning Agency

I. PRE-INTERVIEW CHECKS
To be completed by Crewing PIC or Manning Agent
1 Personnel CV with complete sea service records received Yes No
2 CES Test result and wrong answer summary attached Yes No
Does the candidate comply with the company’s recruitment criteria?
3 If no, state the variance below: Yes No

4. COC Authentication Check – to attached documentation proof / copies Yes No

5. Any security issues/ beliefs

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 3.01 – Crew Application Form including Crew Author: DPA
Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

6. Copies of seaman book records provided for vetting Yes No

Does the candidate hold the training as per Company’s Minimum Training Criterion
for the proposed rank.
7. Yes No
If no, state the variance below:

Any Comments By Crewing PIC or Manning Agent :

Name: Designation:

Date Signature:

J . Manning Agency Questionnaire

Does the candidate accept Company’s Standard wages?
1 If no, please specify requested wages below: Yes No

Has the candidate frequently changed Companies (i.e. <2 contracts/ Company) ?. If
2 yes, please specify why below: Yes No

3 Number of unfinished contracts in the past?

Please specify reason:

4 Reason for leaving last employer?

5 Why does the candidate apply with us and what are his future plans?

6 What are the candidate’s expectations from his next Employer? Any Special
Requests?

7 Has the candidate sailed with multi-national crew?

If yes, please list nationalities:

8 Does the candidate have any dietary requirements?

If yes, please specify:

9 In which areas have the candidate previously traded?

Please specify:

10 Is the candidate agreeable to trade in High Risk Areas, such as Gulf of Aden or Yes No
West Africa?
11 Does the candidate have previous experience on UMS vessels (Engineers only)? Yes No
12 Which engine types does the candidate have experience working with (Engineers
only)?
Please specify:

13 What type of Planned Maintenance System (PMS) does the candidate have

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 3.01 – Crew Application Form including Crew Author: DPA
Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

experience with?
Please specify:

14 Does the candidate have any dry docking and/or major repair experience?
Please specify: Yes No

15 Has the candidate’s CES test wrong answers been shared with the candidate for his
improvement? Yes No

K.REFERENCE CHECK

Name of Company:

Contact Person / Designation:

Address and Contact No:

Reference Check Outcome:

Police Clearance (if any)

L . INTERVIEW CONCLUSION
Above Below
Excellent Average Poor
Average Average
Appearance
Confidence
Professional Aptitude
Communication Skills
English Proficiency
Willingness for Training
Awareness on Cross
Cultural Values & Attitudes
Interviewer’s conclusion and comments:

Any Additional Training Requirement identified during the interview

(If YES, please list the training courses to be done prior joining)
Yes No

Office Visit in Ship Manager or Manning Office – If NO , please remark reason :

Yes No

Name of Signature:
Page 9 of 10
 3.01 – Crew Application Form including Crew Author: DPA
Approved by: COO
Interview & Pre-Employment Checklist – Rev: 5
Manning Agency Issued:1 March 2023

interviewer:
Date:
Manning Agency:

Status
(Recommended for 2nd Interview / Approved / Keep in view / Rejected)

* Part 1 - To be Completed by Applicant

** Part 2 - To be Completed by Manning Agency

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