PT Perusahaan Pelayaran EQUINOX

APPLICATION FORM
A. PERSONAL
Photo
Name :
Date of Birth & Place :
Nationality :
Religion :
Address :
Telephone number : Position applied :
Email Id : KPI No. :
Marital Status :
Number of children : Height :
Weight :
Next of Kin (NOK) :
Address : Size of working cloth :
Telephone number : Size of Shoes :
Email Id :

B. PERSONAL DOCUMENT

Description Number Date of issue Date of expiry

Passport

Seaman's Book

Flag State License

C. COURSES

Description Date of issue Certificate No. Validation

Advanced Tanker Safety - Oil

Advanced Tanker Safety - Chemical

Advanced Tanker Safety - Gas

Tanker Familiarization

COW - IGS

Deck Watch Keeping

Engine Watch Keeping

Medical First Aid Training

Medical Care

Advanced Fire Fighting

Basic Safety Training

Survival Craft Rescue Boat

GMDSS - GOC

ARPA simulator

Radar Simulator

ISM Code Training

Bridge Team Management

Bridge Resource Management

Engine Team Management

Ship Security Officer (SSO)

PT PP Equinox Application Form Page 1 of 2

D. MARITIME LICENSE

Type Certificate No. Date of issue Issued by

E. SEA SERVICE RECORD

Position Vessel IMO type GRT/BHP Flag Period Management

F. MEDICAL RECORD
Last Medical Check Up:
Date Taken Date Taken
MCIS Yellow Fever
Vaccination
Extensive Cholera
Medical Simple Typhoid
Test Drugs Clinic
Form
Clinic

G. INTERVIEW RESULT
Personality Work understanding English Ability to Expr Himself
Attitude Record of Experience Team Work Education

1 : Poor 2 : Below Average 3 : Averange 4 : Good 5 : Very Good 6 : Excellent

Date,

Applicant / Signature

PT PP Equinox Application Form Page 2 of 2