SEAFARER EMPLOYMENT APPLICATION FORM

Recent
Passport
Photograph

POST APPLIED FOR :

MASTER

(Please read form carefully before attempting to fill in, where not applicable
state N.A.. Copies of certificates/testimonials etc. should be attached to the
form.)
Agency Name :

A) Type of vessel applying for : (Plase Tick)

Tanker (>20000 DWT)

GP Tanker (< 20000 DWT)

(I) PERSONAL PARTICULARS

Last/Surname Name
KURNIAWAN

Bunker Barge

Given Names (as in passport)

ANDI EKO KURNIAWAN

Present Address: Jln.RH.Fisabilillah - Mutiara Villa

# block C-2 Tg.pinang Indonesia.
Phone No:(Country Code)+(Area Code)+(Tel No)

Email:andkurniawan@gm
Shoe
Overall
ail.com
Size: 42
Size: XXL
Skype No:(Country
ID:
Mobile
Code)+(Area Code)+(Mobile No)
+62-81390544666 , +62-85724777000

Date of Birth
24 Feb 1974

Nationality
Indonesia

Place and Country of Birth

Tg.Pinang Indonesia

( II ) FAMILY BACKGROUND
Next of Kin
Rini Lestari

Relationship
Wife

Religion
Moslem

Marital Status
Married

(Husband/Wife if married;Father/Mother/Guardian if single)

Address of Next of Kin: Jln. RH. Fisabilillah - Mutiara Villa # block C-2 Tg.pinang Indonesia
Telephone No :
Childrens Name (if applicable)

Mobile
Phone
No
:+62- Email :
85264166295
Sex Age Occupation

2)Khemal Akbar

12

Study

3)Keisha Andani

Study

4)
(III) HIGHEST ACADEMIC QUALIFICATION
From
To
Institutions/Universities attended
Oct 2012
April 2013
Merchant Marine University STIP
Jakarta
(IV) DOCUMENTS AND CERTIFICATES
Personal Document
International Passport with 2 blank page

Document
No.

Qualifications
Class 1 ( ANT 1 )

Issue Date
26 july 2012

Expiry Date
26 july 2017

Issued by
KBRI Spore

Seaman Passport (If Any)

Discharge book (CDC)

STCW Certificate
Certificate Of Competency (COC)
Indicate Grade : __________________
A IV/2 General Operators Certificate
(GOC) : (Deck Officers only)
A V/1-1 Oil Tanker Familiarization

Note: Retention period of completed form is permanent if employed.

OT/C/CRW/1113/001
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30 april 2007

STIP JKT

25 june 2012
20 march
2007

A V/1-1 Chemical Tanker Familiarization

A V/1-2 Advance Oil Tanker
A V/I-2 Advance Chemical Tanker
A VI/1 Safety Familiarization & Basic
Safety Training

25 june 2017
-

STIP JKT
STIP JKT

16 june 2014

Bina Sena
JKT

STIP JKT

A VI/4-1 Medical First Aid

20 march
2007
13 des 2001

STIP JKT

A VI/4-2 Medical Care

25 jan 2002

STIP JKT

A VI/5 Ship Security Officer

03 may 2011

STET Spore

A VI/2 Proficiency in Survival Craft and

Rescue Boat Other Than Fast Rescue
Boat
A VI/3 Advance Fire Fighting

A VI/6 Security Awareness Training

A VI/6 Seafarers with Designated Security

Duties

Ship Handling Certificate (For Master)

ECDIS Training Certificate

Bridge / Engine Team Management

MEDICAL AND VACCINATION

March 2014

BP3IP JKT

Medical Examination (MLC )

June 2013

Sea Care
spore

Yellow Fever

Cholera Vaccination
*
delete
whichever
is
not
applicable
(V) DETAILS OF SPECIAL TRADE
Experience on Inert Gas Tanker: YES / NO *

Experience on Chemical Tanker: YES / NO*

Experience with USCG (TVEL): YES / NO*

Experience on STS:

PSC Experienced:
Trading Area:

NO

YES / NO*

Vetting Inspection Experienced:

NO

Spore waters and West Msia waters

Types of Cargo experience With: MGO and MFO

Experience with Nationalities :
Total Sea Service time on Oil Tanker :

132

mths

Total Sea Service time on Chemical Tanker :

NONE

mths

Total Sea Service time on All Tanker :

132

mths

Total Sea Service time Present Rank :

Total
Total Sea
Sea Service
Service time
time On
: Present Rank:
(VI) ADDITIONAL INFOMATIONS
Command of English
CES Test Result:
Last Company Name:
Southernpec Ship Mgmt

60

mths
mths
mths

168
mths

Poor

Satisfactory
%

Person In Charge:
Capt. Xiao rong boo

Marlin Test result:

Phone:

S$ 6500

Note: Retention period of completed form is permanent if employed.

OT/C/CRW/1113/001
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%
Email:

Reason for Leaving Last Company : Finish contract

Last Salary:

Good

Readiness:

(VII) DETAILS OF SEA SERVICE

Company

Vessel
Name

Vessel
Type

GRT

Type of
Engine

(VIII) MEDICAL HISTORY / BACKGROUND

* delete whichever is not applicable
Height :
Weight:
a)

BHP/
KW

Rank

Period
From
To

Total
Months

Chest Span :

Do you have any history of family or personal illness such as Tuberculosis, High
Blood Pressure, and Mental Illness etc?
b) Have you ever been hospitalised, operated or currently undergoing some kind of
medical treatment?
c) Do you have an emotional or physical handicap (disability)?
d) Have you ever been charged in court for any offence?
e) Have you ever served on or applied to Ocean Tankers (Pte) Ltd or affiliated
concerns of Ocean Tankers (Pte) Ltd?
f)
Have you been involved in a maritime incident before?
If any of the answer is Yes, please give details below
a.Only blood pressure, but under control and medical treathment by doctor and medicine.
b.Hospitalised and operated in spore hospital in MEH by motor bike accident on may14

Yes/No*
Yes/No*
Yes/No*
Yes/No*
Yes/No*
Yes/No*

(IX) DECLARATION BY APPLICANT

I certify that all statements given on this application are correct and true to my knowledge. I also
understand that falsification or misrepresentation ( intentionally or unintentionally ) in this or any other
personnel records can result in my immediate dismissal and forfeiture of all wages, allowances and
benefits if I am employed by the Company. I do agree to submit myself to a thorough medical examination,
which I must successfully pass as one of the conditions for being accepted for employment.

Andi eko kurniawan/ 19/9/2014

Signature of Applicant / Date

Note: Retention period of completed form is permanent if employed.

OT/C/CRW/1113/001
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