PT JASINDO DUTA SEGARA

Address : Jl. Raya Boulevard Barat Plaza Kelapa Gading Rukan Blok C / 55 Jakarta 14240 Indonesia
Tel : +62-21-4585-1225(Hunting) / Fax : +62-21-4585-1228
Info@jasindods.co.id ; www.jasindods.com

APPLICATION FORM
Date of Readiness : . . . (DD.MM.YYYY)
Name (in full) Rank Vessel

Place & Date of Birth : / Height : cm

Province : Weight : kg PHOTO

Marital Status : Blood Type :

Children : Clothe's Size :
Religion : Shoes Size : mm

Address :
Pos Code :
Contact Person : Telp. / HP :

Education
Formal Place Year Remark
1 Senior High School
2 Maritime Education

Certificate of Competency:
Grade STCW '95 Place and Date of Issued Expire Date Number of Certificate
1 A.N.T I / II / III
2 A.T.T I / II / III
3 WATCHKEEPING

Certificate of Proficiency
Type Y/N Place and Date of Issued Expire Date Number of Certificate
1 Endorsment
2 BST
3 AFF
4 SCRB
5 Medical First Aid
6 Medical Care
7 ARPA
8 RADAR
9 BTM/BRM
10 GOC
11 GMDSS
12 SSO
13 ERM
14 BRM
15 SSAT / SDSD
16 FOOD HANDLING
17 Other:
18 Other:

Documents
Type Number Date of Issued Expire Date Place of Issued
Passport
Seaman Book
Panama Rank Certificate
Panama GOC/GMDSS Cert
USA Visa
MCV Australia
Sea Service Experience
Vessel / Route / GRT / Ship's type (*) Company / Sign Salary
Rank Reason
Flag Mixed Crew HP Engine Agency On / Off (USD/month)

English Language
Qualification Good Fair Poor Remark
Writing
Speaking
Reading

Others
Other skilled : Uncompleted Working Contract : Vessel
Drug/alkohol Drink : Total Exper. in foreign flag ship : Vessel

Date :

Acknowledgement:
I, the seafarer declare that the above data are correct and true, and
I do not pay anything for doing this process.