1. SEAFARER APPLICATION FORM
POSITION APPLIED FOR: BOSUN / AB
PERSONAL DETAILS
Surname Middle Name Last Name Nationality
LAODE ALI
KAIMUDDIN
ALI KAIMUDDIN INDONESIA
Date of Birth Place of Birth Religion Age
25-09-1976 BUTON MOESLEM 39
Education Qualification COC Grade Marital Status Height/Weight
HIGH SCHOOL DECK WATCH MARRIED 167 / 80
Passport Number Issuing Authority Date of Issue Date of Expiry Overall Size
B 0356662 INDONESIA 03-02-2015 03-02-2020 XL
Seaman’s Book Number Issuing Authority Date of Issue Date of Expiry Safety Shoes Size
X 023942 INDONESIA 05-03-2013 05-03-2017 42
Mobile Phone Number House phone Number Email Address Hometown
Airport
+6281282071037 - ODEQILA@GMAIL.COM
HANGNADIM
BATAM
ISLAND
MEDICAL
EXAMINATION
083700
MALAYSIA SEAMAN ID
NUMBER
201523049578
PETRONAS MEDICAL C 132492 OFFSHORE SAFETY PASSPORT B 142492
Permanent Address : JL. KAWAL PANTAI TRIKORA BINTAN KOMPLEKS GRIYA MAWADDAH BLOK
B/29 Riau Island. City of Tanjung Pinang INDONESIA
NEXT-OF-KIN
Name : WAODE NURHAYATI Relationship Contact Number
WIFE +6281350507385
Address (if different from the above)
JL. KAWAL PANTAI TRIKORA BINTAN KOMPLEKS GRIYA MAWADDAH BLOK B/29
Officer Certification (STCW)
Certificate
Number
Issuing
Authority
Date of
Issue
Date of
Expiry
Certificate of Competency
CLASS V
6201116775N50213 INDONESIA 31-10-2013
Endorsement 6201116775NE0213 INDONESIA 01-11-2013
General Operators Radio
Certificate
43591/SOU/II/2015 INDONESIA 27-02-2015 27-02-2020
GMDSS 6201116775G10115 INDONESIA 18-03-2015 18-03-2020
Rating Certification (STCW)
Certificate
Number
Issuing
Authority
Date of
Issue
Date of
Expiry
COC Watchkeeping / ANTD 6201116775N60210 INDONESIA 02-06-2010 -
STCW CERTIFICATE
Certificate
Number
Issuing
Authority
Date of
Issue
Date of
Expiry
Basic Safety Training 6201116775010710 INDONESIA 04-03-2015 04-03-2020
Survival Craft & Rescue Boat 6201116775040115 INDONESIA 02-02-2015 02-02-2020
Advanced Fire Fighting 6201116775060115 INDONESIA 02-02-2015 02-02-2020
Medical Care 6201116775080213 INDONESIA 09-01-2013 09-01-2018
Ship Security Officer 6201116775240714 INDONESIA 09-05-2014 09-05-2019
Medical First Aid 6201116775070212 INDONESIA 03-12-2012 03-12-2017
Security Awareness Training
(STCW 2010)
6201116775310714 INDONESIA 20-10-2014 20-10-2019
SEAFARERS WITH DESIGNATED
SECURITY DUTIE
6201116775320715 INDONESIA 05-03-2015 05-03-2020
TANKER FAMILIARIZATION 6201116775090212 INDONESIA 11-12-2012 11-12-2017
FAST RESCUE BOAT / FRC 6201116775050115 INDONESIA 27-03-2015 27-03-2020
OFFSHORE CERTIFICATE Certificate Issuing Institute Date of Date of

2. & DOCUMENT Number Issue Expiry
OFFSHORE SAFETY PASSPORT B 142492
PETRONAS
MALAYSIA
15-10-2015 15-10-2017
TBOSEIT (OPITO Approved) 008713
PT. SAMSON
TIARA
14-03-2013 14-03-2019
Rigging & Slinging
BSTS/SDP-
06/06239/15
BORNEO SAFETY
TRAINING
SERVICE Sdn. Bhd
17-10-2015 17-10-2018
Crane Operator 1730913000787
BARRON
INTERNATIONAL
SCHOOL
11-09-2013 10-09-2019
Record of Sea Service
Company
Name of
Vessel
Type GT BHP Rank
Trading
Area
Scope of
Operations
From To
MMA
OFFSHORE
SINGAPORE
JAYA
MAJESTIC
AHTS
DP.2
3607 12170 Bosun MYANMAR
YETAGUN
MYANMAR 15-10-15 23-01-16
JAYA
OFFSHORE
SINGAPORE
JAYA
MAJESTIC
AHTS
DP.2
3607 12170 Bosun MALAYSIA
LABUAN,
MIRI 13-05-15 11-08-15
PANAMA /
FUGRO
MARINE
SERVICE
ENDEVOUR
AHTS 1514 8120 Bosun AFRICA
KONGO,
ANGGOLA,
GABON
22-04-14 19-12-14
PANAMA /
FUGRO
MARINE
SERVICE
FUGRO
GEMINI
AHTS 1865 8120 Bosun THAILAND
THAILAND
GULF
17-09-13 27-03-14
PANAMA /
SEA HORSE
LTD
MV. STI
MARS TOING
TUG
292 3200 AB
UAE /
PERSIAN
GULF
DAS ISLAND
19-01-12 10-10-12
SINGAPORE
/ YEW
CHOON
MARINE
TB. YEW
CHOON 2 TOING
TUG
255 2400 AB SINGAPORE SINGAPORE
01-04-11 03-12-11
SINGAPORE
/ ASL
MARINE
TB. ASL
FALCON
TOING
TUG
365 3200 AB MALAYSIA KEMAMAN
11-08-10 29-03-11
PT. BARUNA
RAYA
LOGISTIK
SV.
CENDRAWA
SIH
AHTS
DP 1
1650 5120 Bosun INDONESIA
KALIMANT
AN
04-03-07 04-04-09
PT. BARUNA
RAYA
LOGISTIK
SV. GAGAK
AHTS
DP 1
2120 8710 Bosun INDONESIA
KALIMANT
AN
14-01-05 04-12-06
PT. BARUNA
RAYA
LOGISTIK
SV.
KASUARI
AHTS
DP 1
1876 5120 Bosun MALAYSIA KEMAMAN 13-07-03 06-09-04
PT. BARUNA
RAYA
LOGISTIK
SV. UNDAN
AHTS
DP 1
1648 6120 Bosun MALAYSIA KEMAMAN 04-01-02 28-05-03
Applicant’s Signature: La Ode Ali Kaimuddin