1. SEAFARER APPLICATION FORM
CSI-OMS-PR-04-F11
CONTROLLED Revision: 18 Nov 2013
Approved by DPA/MR
Page 1 of 2
Name (As in Passport) SUKRI SUKISMAN
Address
JI Negara Gang Kakalati Tanah Periuk Paser Kalimantan Timur
Religion Muslim Weight (kg) 71kg
Marital Status Married Height (cm) 169cm
Nationality Indonesian Date of Birth 03 Sep 1979
Telephone/Mobile +6281372502624 Position Applied Able Bodied Seaman
Email Address sukrisukisman@yahoo.com
NEXT OF KIN
Name Sitti Alang Relationship Wife
Address
JI Negara Gang Kakalati Tanah Periuk Paser Kalimantan Timur
Contact Number +6281372502624 Email Address sukrisukisman@yahoo.com
TRAVEL DOCUMENT INFORMATION
Passport No / Origin A 8304431/Indonesia Expiry Date 03 Jun 2019
Seaman Book No. C084999 Expiry Date 24 Aug 2017
COMPETENCY CERTIFICATES
Certificate of Competency No. (COC) Nil Expiry Date
COC Certificate of Endorsement No. Nil Expiry Date
GMDSS Operator Certificate No. (GOC) Nil Expiry Date
GOC Certificate of Endorsement No. Nil Expiry Date
Watch Keeping Certificate No. 6200409562N60604 Expiry Date N/A
OTHER CERTIFICATES
CERTIFICATES NO DATE ISSUED EXPIRY DATE
Basic Safety Course 6200409562010610 14 April 2010 No Expiry
Advanced Fire Fighting Nil
Medical First Aid Nil
IMDG Course Nil
Proficiency in Survival Craft and Rescue
Boat
6200409562040610 19 April 2010 No expiry
Auto Radar and Plotting Aids (ARPA) Nil
Fast Rescue Boat (FRB) Nil
Ship Security Awareness STET MAR-PISA-14-01-2089 25 Nov 2014 No expiry
Designated Security Duties
STET MAR- PIDSD-14-01-
1892
25 Nov 2014 No expiry
Onboard Medical Care Nil
Bridge Team Management (BTM) Nil
Bridge Resource Management (BRM) Nil
Dynamic Positioning Course Nil

2. SEAFARER APPLICATION FORM
CSI-OMS-PR-04-F11
CONTROLLED Revision: 18 Nov 2013
Approved by DPA/MR
Page 2 of 2
OFFSHORE CERTIFICATES
CERTIFICATES NO DATE ISSUED EXPIRY DATE
HUET 841757071602130007 16 Feb 2013 15 Feb 2017
Personal Survival Technique “ “ “
BOSIET (OPITO Approved) “ “ “
Helideck Landing Officer (HLO) Nil
Helideck Assistant (HDA) Nil
Travel Safely by Boat (TSBB) 841757071602130007 16 Feb 2013 15 Feb 2017
Rigging and Slinging 59/12 28 Sept 2012 No expiry
MEDICAL CERTIFICATES
STCW Medical Examination
Date Issued 18 Jun 2014 Expiry Date 19 Jun 2016
Offshore Medical Examination
Date Issued N/a Expiry Date
Date Issued N/a Expiry Date
RECORD OF SEA SERVICES
N
o
Vessel Name Type Rank Company Trading area
Sign On
Date
Sign Off
Date
Sea Time
Years/Months
1 Crest Hydra DSV AB Crest Subsea Singapore 20.04.15
2 Crest Odyssey 1 DSV AB Crest Subsea
Singapore &
Indonesia
16.10.14 10.12.14
1 month 24
days
3
Crest Odyssey
1
DSV AB Crest Subsea Singapore 22.01.14 04.08.14
6 month 13
days
4
DS. Stephani
Turn
DSV AB Offshore Works Singapore 06.05.10 16.09. 10 4 mths 10 days
5 DS Stephani Turn DSV AB Offshore Works Singapore 05.01.10 21.04.10 3 mths 16 days
6 DS Stephani Turn DSV AB Offshore Works MALAYSIA 27.08.09 24.11.09 2 mths 27 days
7 Leisure World Cruise AB New Century SINGAPORE 11.02.06 31.07.07
15 mths 20
days
8 AD Pegasus PSV AB Lunar Shipping MALAYSIA 23.08.05 29.12.05 4 mths 6 days