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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
& DOCUMENT
Certificate
Number
Issuing Institute
Date of
Issue
Date of
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

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Laode ali seafarer application form1

  • 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
  • 2. OFFSHORE CERTIFICATE & DOCUMENT Certificate Number Issuing Institute Date of Issue Date of 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