Dear Sir,

I intend to aplly a job at your company for the position as AB, and I am ready to be planned on the board
with route of voyoges determined by the company offer. Here below my complete data:

JOB APPLICATION FORM

I. Personal Information
Name Binsar Suraya Butarbutar
Rank AB
Place/DateBirth Pabatu, December 21th 1968
Sex Male
Perum. BTN Gunung Putri Permai
Address Jl. Rambutan I No : 19 – 20 RT.04 / RW.10
Kel. Karanggan, Kec. Gunung Putri
Email surayacsp@yahoo.com
Mobile Phone +62812 1373 7395, +62813 8108 8585
Nationality Indonesia Religion Christian Status Merried
Eyes Brown Hair Black Height 165 cm
Weight 60 kg Shoes size 40 cm Waist 32 cm
Name Sontiana Sagala Relation Sister
Perum.Ciriung Cemerlang Blok
Next of kin Permanent
AD No.2 RT:08 14 Kel Ciriung Phone +6281387353125
Address
Cibinong-Bogor
II. Document Held
No Type Document Number Place/date of issued Date expire
1 Passport U 171560 T. Priok, 14 May 2010 Nov 04th 2014
2 Seamen’s Book W 065753 T. Balai, 28 Oct 2009 Oct 19th 2012
3 NPWP 26.464.774.4-403.000 Bogor - Jawa Barat
III. Certificate of competency
No Type of competency Number Place/date of issued
1 ANT-D 6200569299N60710 Pertamina Jakarta, Jan 28th 2010
IV. Certificate Profictence
No Type of certificate Number Place/date of issued
1 Basic Safety Training (BST) 6200569299010109 STIP Jakarta, Oct 07th 2009
2 Survival Craft and Rescue Boats (SCRB) 6200569299040109 STIP Jakarta, Oct 12th 2009
3 Medical First (MFA) 6200569299070109 STIP Jakarta, Oct 15th 2009
4 Tanker Familyration (TF) 6200569299090109 STIP Jakarta, Oct 30th 2009
Oil Tanker Specialized Training
5 6200569299100110 STIP Jakarta, Nov 01st 2010
Programme
V. Sea Service Record
Vessel Vessel Rank Sign
No GRT / HP Company Reason
name / Flag Type On Off
1 MT. Kristian Tanker AB 3400/2700 20 Jun 10 05 Nov 10 PT. Deli Maju Finish Contract
TB. Dewi Tug PT. Samudra
2 AB 270/2x1500 02 Peb 10 05 Jun 10 Finish Contract
Shinta Boat Line
PT. Jala Arung
3 KM. Anson Cargo OS 172 05 May 08 07 Jan 09
Samudera
Finish Contract

I declare that information contained above is correct to the best of knowledge, thank you for kind attention
and I am looking forward for your response.

Sincerely yours,

Binsar Suraya Butarbutar