MICLYN EXPRESS OFFSHORE PTE LTD

3 HarbourFront Place
#11-01/04 HarbourFront Tower 2,
Singapore 099254
Website: www.meogroup.com

Crew Application Form

L3-V2-1 Form 1 Rev 2

Date 20-Mar-17

POSITION APPLIED chief officer

LATEST PHOTO
(Passport Size)
Date of Availability ANYTIME

Nearest Airport JAKARTA

PERSONAL PARTICULARS
Name jemmy juventius Rank chief officer
Date Of Birth 03 january 1981 Place Of Birth mandai
Marital Status single Nationality indonesia
Religion christian Blood Group ab
E-mail jemmyjuventius@yahoo.com PPE Size L
Home Tel. No - Mobile No. 82290190808
Height (cm) 168 Weight (kgs) 62
pondok sudiang ASRI 1, tanah kapling, sudiang, daya, makassar, 90242
Home Address
Postal Code: 90242
TRAVEL DOCUMENTS NUMBER DATE OF ISSUE DATE OF EXPIRY PLACE OF ISSUE
Passport B 1510251 15 July 2015 15 July 2020 Makassar
Seaman Book C 076438 07 JULY 2014 07 July 2017 Jakarta

CERTIFICATE OF COMPETENCY CAPACITY DATE OF ISSUE DATE OF EXPIRY

Certificate of Competency (Home Country) MANAGEMENT LEVEL 2-Feb-16 PERMANENT

Certificate of Endorsement (Home Country) MANAGEMENT LEVEL 10-Feb-16 10-Feb-21

General Operator Certificate (GOC) (Home Country) 6200078937G10115 27-Nov-15 27-Nov-20

FLAGSTATE DOCUMENTS CAPACITY DATE OF ISSUE DATE OF EXPIRY

Singapore /Panama/ Malaysia / indonesia- COE / COR NA
Singapore /Panama/ Malaysian / Indonesia - GOC / COR NA
Singapore /Panama/ Malaysian / indonesia - SIRB / SID NA

MEDICAL CERTIFICATE CLINIC DATE OF ISSUE DATE OF EXPIRY

Petronas / BSP / PANAMA NA
Others : NA
NOS. TRAINING CERTIFICATES DATE OF ISSUE DATE OF EXPIRY
1 Basic Safety Training
2 Personal Survival Techniques
3 Fire Prevention and Fire Fighting
4 Elementary First Aid
5 Personal Safety and Social Responsibilities
6 Proficiency in Fast Rescue Boat
7 Advance Firefighting
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 8 Medical First Aid
9 Proficiency in Survival Craft and Rescue Boats
10 Radar Observation
11 Automatic Radar Plotting
12 ARPA Simulator
14 Radar Simulator
13 Ship Security Officer (SSO)/ Security Awareness(SAT) / Designated Security Duties(SDSD)

14 Bridge Resource Management

15 Engine Room Resource Management
16 Global Maritime Distress Safety System (GMDSS)
17 Food handling Certificate (COOK)
18 Medical Care Onboard
19 BOSIET
20 HUET
21 DP Maintenance
22 DP Simulator
23 Rigging & Slinging Certificate
24 HLO / HLA
25 Proficiency in Fast Rescue Boat (PFRB)
26 Electronic Chart Display AND Information System (ECDIS)
NEXT OF KIN (NOK) DETAILS (to be contacted in case of Emergency)
Name Relationship

Address
Tel. No
SPOUSE PARTICULARS
Spouse Name Date of Birth

Address
Tel. No
DEPENDENTS / CHILDREN PARTICULARS

nos. Name Relationship Date of Birth Age

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 MICLYN EXPRESS OFFSHORE
CREW APPLICATION FORM
L3-V2-1 Form 1 Rev 2

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