PT GEMILANG BINA LINTAS TIRTA

SEAFARER APPLICATION FORM C - 06

Position Applied
C/OFF
Date available Application Date

Manning Agent For Vessel

MT BULL KANGEAN
Certificate
D CLASS I

Full Name (Underline Surname) ENDE NURJAMAN Nationality Indonesian

Place of birth TASIKMALAYA Date of Birth 27 Jan 1971 Weight (Kg) Height (Cm)

Marital Status Married Name of Spouse No. of Children 3

Tel: (Home) 081323523132/081510884242 Name of Next of Kin RATNA KURNIA

Tel: (Mobile)

Email: Relationship Tel

Address Wife
DUSUN KRAJAN II RT/RW 06/004 KUTA GANDOK, KARAWANG - JAWA BARAT Address of Next of Kin

Most Convenient Airport

Passport B 3544796 Issue at KARAWANG Issued Date Expiry Date

Seaman Book No D 000715 Issued at TANJUNG PRIOK Issued Date Expiry Date

U S A Visa (Type) Issued at Issued Date Expiry Date

Singapore Visa (Type) Issued at Issued Date Expiry Date

Certificate of Competency No Issued at Issued Date Expiry Date

6200060827N10216 JAKARTA 26 Oct 2007
Certificate of Endorsement S'pore (COC) No Issued / Expiry Certificate of Endorsement S'pore (GOC) No Issued Date / Expiry Date
6200060827NA0216 11 Feb 2016 11 Feb 2021 COE-D0009700 04 Dec 2007

Details of Previous Sea Service

Rank Vessel Name Sign On Sign Off
C/OFF BULL KALIMANTAN 14 Jan 2018 20 Feb 2019
C/OFF BULL PAPUA 30 Jan 2017 11 Dec 2017
C/OFF BULL FLORES 16 Jun 2016 20 Dec 2016
C/OFF GANDINI 26 Nov 2014 30 Aug 2015
C/OFF DEWI SRI 28 Apr 2014 24 Jul 2014
C/OFF DEWI SRI 01 Nov 2013 08 Apr 2014

C/OFF DEWAYANI 18 Dec 2012 28 Aug 2013

C/OFF RENGGANIS 14 Oct 2011 05 May 2012

C/OFF NOLOWATI 15 Oct 2010 05 Jun 2011
C/OFF YANASENI 01 Dec 2009 11 Jul 2010
C/OFF PERTIWI 11 Jan 2009 20 Aug 2009
C/OFF YANASENI 28 Feb 2008 23 Sep 2008
2/OFF YANASENI 25 Nov 2007 27 Feb 2008
2/OFF YANASENI 25 Nov 2005 20 Oct 2006
2/OFF EROWATI 31 Aug 2004 08 Aug 2005
2/OFF GANDINI 28 Jun 2003 17 Jul 2004
3/OFF GANDINI 11 Feb 2003 27 Jun 2003
3/OFF EROWATI 25 Jun 2001 16 Aug 2002
3/OFF CENDANAWATI 08 Sep 1999 17 Oct 2000
3/OFF FATMAWATI 01 May 1998 24 May 1999
JR DECK FATMAWATI 28 Sep 1997 30 Apr 1998
CDT/N GAS INDONESIA 06 Dec 1995 07 Dec 1996

Details of Previous Sea Service

Rank Vessel Name Vessel Type KW DWT Sign On Sign Off Name of Company
 PT GEMILANG BINA LINTAS TIRTA
SEAFARER APPLICATION FORM C - 06

Qualification Document. No. Issued Date Expired Date Issue By Declaration To Be Signed By the Applicant

Basic Safety Training (BST) 6200060827211116

Survival Craft and Rescue Boat (SCRB) 0052/SH&MC/X/DIKSUS-PK I hereby certify that the information contained

Tanker Familiarzation (TF) 6200060827060114 in this form is complete & correct. I understand that
Advanced Fire Fighting (AFF) 6200060827080114 the Company may terminate my service at any time
Medical First Aid (MFA) 6200060827070114 if any of the above information is found to be false.
Medical Care (MC)
Ship Security Officer (SSO) 6200060827040114
Security Awareness Training (SAT) 6200060827090102
Security Awareness Training for Seafarer
Designated security Duties (SDSD)
Crowd Management Training (CMT) 6200060827100116
Crisis Management Human Behaviour Tr4aining
(CMHBT) 6200060827110116
Basic Oil and Chemical Tanker (BOCT)
Basic Liquified Gas Tanker (BLGT)
Advanced Oil Tanker (AOT)
Advanced Chemical Tanker (ACT) 6200060827010114
Advanced Liquified Gas Tanker (ALGT)
Radar Simulator (RS) 6200060827290216
Arpa Simulator (AS)
Bridge Resource Management (BRM) 6200060827230212
Electonic Chart Display and Identification
system (ECDIS)
Engine Room Resource Management (ERM) 4030908087507
Global Maritime Distress Safety System
(GMDSS) L/AC-02932
Fast Rescue Boat (FRB)
Passanger Safety Cargo Safety and Hull Integrity
Training ( PSCSHIT) ...……………… ………..……………………
Safety Training

Date Signature of Applicant

PPE & Clothing Size

Safety Shoes: Boiler Suit: Winter Jacket: Long John (Upper): Long John (Lower):
For Officers Only: White Shirt: Blue Pants:
Available Sizes
Safety Shoes Sizes : 5, 6, 7, 8, 9, 10, 11, 12.
Boiler Suit / Winter Jacket / Long John Sizes: XS, S, M, L, XL, XXL.
White Shirt Sizes: S, M, L, XL
Blue Pants Sizes (Inches): 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40.

For Office :

Interview by / Date : / Department : Status : Approved / Rejected

Comments :
1. APPROVE FOR JOIN MT. …………………………………... AS …………………

WITH PROBATION 3 MONTH