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EXECUTIVE OFFSHORE BIODATA / PRE JOINING FORM (09/16 Rev 2)

A. Personal Data (NAME should be strictly as per Passport )

First Name MOHAMAD HILMIN Middle Name BIN Surname MOHAMAD ROZI
Nationality MALAYSIA Place of Birth
KOTA BHARU,KELANTAN Date of Birth 03.07.1997
Yes /
Post Applied For OILER Willing to sail in lower rank? Available From 4/4/2019
No
Yes /
Smoker / Non-smoker Do you know swimming? Religion MUSLIM
No
Permanent address

46,TINGKAT 3,BLOK 44,JALAN CENDANA 10,TAMAN CENDANA

AFFIX RECENT PASSPORT
Postal code 81700 City PASIR GUDANG State JOHOR SIZE PHOTO HERE
Country MALAYSIA

Contact Details Tel No. Mob No. 60149147897

Email hilmin.career@gmail.com

B. Travel Documents
Passport No. Date of Issue Date of Expiry Place of Issue ECNR (Y/ N/ NA) Min. 3 blank pages (Y/ N)
A50284781 9/2/2018 9/2/2023 UTC PASIR GUDANG NA Y
Date of Issue Date of Expiry Place of Issue PAN/ UID Number National ID Number
NA NA NA NA 970703-03-5785
Seaman's Book Details Seaman's Book No. Date of Issue Date of Expiry Issued by (Country) Place of Issue
4585166488A 13/08/2017 NA MALAYSIA PSR GUDANG

Wkeeping License No. Date of Issue Date of Expiry Issued by (Country) Place of Issue
Basic TrainingSTCW2010/PELITAKKB/BT/00460/2018
(BT) 28-04-2018 27-04-2023 MALAYSIA PELITA AKADEMI SDN BHD
Designated Ship STCW2010/PELITAKKB/SDD/00598/2018
Duty (DSD) 10/5/2018 NA MALAYSIA PELITA AKADEMI SDN BHD
WKE 6.11E+118 12/2/2019 NA MALAYSIA LABUAN
GMDSS License No. Date of Issue Date of Expiry Issued by (Country) Place of Issue
NA NA NA NA NA

C. Family
Civil Status (Please mention "Yes" where appropriate): Wedding Anniversary Date (if applicable):
Single / Married Separated Divorced Widowed
Family Name Date of Birth Passport No. Date of Issue Date of Expiry Place of Issue
Wife
Child MF
Child MF
M
Child F
Child MF
D. Physical Details
Height : 178 cms Weight : 62 Kgs Boiler Suit Size (S , M , L , XL , XXL) : M Shoe Size (6, 7, 8, 9, 10, 11) : 8.5
Eye Color : BROWN Hair Color: BLACK Distinguishing Mark : NA

E. Next-of-Kin Details
First Name MOHAMAD ROZI Middle Name BIN Surname HASSAN
Sex: (M/F) MALE Relationship PARENT D.O.B 26/08/1969
Address of Next-of-Kin:
46,TINGKAT 3,BLOK 44,JALAN CENDANA 10,TAMAN CENDANA Postal code 81700 City PASIR GUDANG
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EXECUTIVE OFFSHORE BIODATA / PRE JOINING FORM (09/16 Rev 2)

46,TINGKAT 3,BLOK 44,JALAN CENDANA 10,TAMAN CENDANA Postal code 81700 City PASIR GUDANG
State JOHOR Country MALAYSIA
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EXECUTIVE OFFSHORE BIODATA / PRE JOINING FORM (09/16 Rev 2)

Contact Details Tel. No.

Mob No. 60177604882 Email:

F. Academic Qualification (Highest qualification attained to be mentioned)

Name of the Institution Qualification From To Percentage/ Grade
POLITEKNIK UNGKU OMAR DIPLOMA 2016 2018 PASS

Country MALAYSIA State PERAK City IPOH Postal code 31400

Secondary School Marks % : Higher Secondary School Marks % :

Pre-Sea course details
Name of the Institution Type of Degree From To
POLITEKNIK UNGKU OMAR DIPLOMA 2016 2018
Country MALAYSIA State PERAK City IPOH Postal code 31400

G. Details of Courses & Certificates Number Date of Issue Date of Expiry Issued by
Basic STCW Courses
Advanced Fire Fighting (A-VI/3) AFF
Automatic Radar Plotting Aid ARPA
Basic Fire Fighting BFF
Basic Training STCW2010/PELITAKKB/BT/00460/2018
BT 28-04-2018 27-04-2023 PELITA AKADEMI SDN BHD
Bridge Resource Management BRM
Bridge Team Management BTM
Chemical Tanker Familiarisation
Course (A-VI/1) CTFC
Chemical Tanker Safety Course
CTFC
(A-VI/5)
DP Advance
DP Unlimited
ECDIS IMO 1.27
Elementary First Aid EFA
M
Engine Room Simulator ERS
O
Fire Prevention and Fire
FPFF
Fighting
Medical First Aid (A-VI/4-1) MFA
Medicare (A-VI/4-2) MDC
Personal Survival & Social
Responsibility (A-VI/1-4) PSSR
Personal Survival Techniques PST
Proficiency in Fast Rescue Boat
/ Craft (A-VI/2-2)
Proficiency in Survival Craft
& Rescue Boat (A-VI/2-1) PSCRB
Radar Observer Course
Radar Simulator Course
Root Cause Analysis
Security Awareness STCW2010/PELITAKKB/SA/00558/2018
8/5/2018 PELITA AKADEMI SDN BHD
Security Duties (A-VI/6-2)
Ship Handling Simulator (A-II/2)

Ship Security Officer (A-VI/5) SSO

Ship Safety Officer SOC
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EXECUTIVE OFFSHORE BIODATA / PRE JOINING FORM (09/16 Rev 2)

H. Other Courses Number Date of Issue Date of Expiry Issued by

DP Maintenance
Cookery course

I. Flag Documents Number Date of Issue Date of Expiry Issued by

Singapore (COE)
Singapore (GOC)
Malaysia (COR / GMDSS)
Malaysia (Seaman ID) 201751006337 13-08-2017 12/8/2022 PASIR GUDANG

J. Industry Certificates Number Date of Issue Date of Expiry Issued by

BOSIET (OPITO Approved) 290859062208183669 22-08-2018 21-08-2022 SEQU OFFSHORE SAFETY SDN BHD
H2S
Banksman
Rigging and Slinging
Designated First Aider
Approved Gas Tester
Food Handling

K. Industry Medical Reports Number Date of Issue Date of Expiry Issued by

ILO Medical
Malaysia Marine Department 6/7/2018 5/7/2020 YUSLINA POLYCLINIC(JOHORPORT)
PETRONAS Medicals (PMU) 2/8/2018 1/8/2020 YUSLINA POLYCLINIC(JOHORPORT)

L. Industry Passports Number Date of Issue Date of Expiry Issued by

SHELL Passport A68441 SHELL
PETRONAS - OSP NA

M. Other Documents Number Date of Issue Date of Expiry Issued by

Yellow Fever vaccination YF
Hepatitis A Vaccination
Hepatitis B Vaccination
INDOS Number
Typhoid Vaccination

N. Operational and Cargo Handling Experience

A Operational Experience in current rank
No Item Details
1 Number of Dry Dockings attended 1
2 No. of OVID inspections attended
3 No. of OSVIS inspections
4 Class of ROV (Observation or work class)
5 No. of Ocean Tows carried out
6 No of Rig Moves
7 Flag State Inspection / Port State Inspection No
8 Do you have experience with FMEA Trials No
9 Do you have experience with DP Annual trials No
10 Have you New Delivery / Take over NO
B Special Cargo Handling Experience in current rank
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EXECUTIVE OFFSHORE BIODATA / PRE JOINING FORM (09/16 Rev 2)

1 Have you carried Heavy Lift / Project cargoes No

2 Have you carried DKD Mud NO
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EXECUTIVE OFFSHORE BIODATA / PRE JOINING FORM (09/16 Rev 2)

3 Have you carried Methanol NO

4 Have you carried Glycol NO
C Anchor Handling Experience in current rank
1 Types of anchors handled NO
2 Do you have experience of grappling for anchors NO
3 Do you have experience in Handling and stowage of Chains NO
4 Size and length of chain handled NO
5 Maximum Anchor handling depth you have worked in NO
O. How did you get to know about Executive Offshore (Please mark "Y" where applicable)
Contacted by EO staf Print media Web site Word of Mouth Y

P. References
S/N Name of the company Person in charge Designation Phone No.
1
2

For Office Use only

Q. Medical History
If "Yes", please give
(a) Have you ever signed of from a ship due to Medical reasons? (Please mark "Y" if applicable) NO
details
Name of the vessel Date of incident Brief Decription (Injury/ Illness/ Accident)

(b) Did you sufer or Are you Presently sufering from any Disease likely to render you unfit for Service at Sea or likely to NO
endanger the health of others on board. (Please mark "Y", if applicable)
(c) Are you addicted to alcohol or drugs of any kind. (Please mark "Y", if applicable) NO
(d) Have you sufered from following (Please mark "Y", if applicable)
Malaria Diabetes Epilepsy Nervous Disability Did you ever undergo psychiatric treatment

R. Security Self-Declaration
(Please tick "YES" / "NO") - If any answers is "Yes" then please provide details for our information.
1 Have you ever been convicted of a criminal charge? Yes No /
2 Are you an un discharged bankrupt? Yes No /
3 Are you a member of any political organization? Yes No /
If yes, please specify:
4 Have you ever been dismissed, suspended or gazetted out of service of the government? Yes No /
5 Are you part of any banned organization in the country of your residence or internationally? Yes No /
I warrant and represent that:
1 The foregoing details are true and accurate and complete
2 There are no contractual or other restrictions (other than official Visa/ Work Permit approvals) or health conditions that may in
any way Prevent or restrict me form being employed by you and fully performing my work.
3 I apply for employment with you by my own free will without any inducement or representative from you or your agents.
4 Further that no Certificate of competency or license issued to me has ever been revoked or suspended.
5 I also certify that my medical history contained above is true and any false statement or undisclosed Material information about
past illness or injury will disqualify me from any employment benefits and claims.

Date: 4/Mar/19 Rank: OILER Signature of Seaman:

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EXECUTIVE OFFSHORE BIODATA / PRE JOINING FORM (09/16 Rev 2)

For Office Use only

INITIAL CHECK & VERIFICATION (Please mark "Y", if applicable)
A. Original licenses sighted
B. STCW and Training Certificates sighted

Name: Designation: Signature: Date:

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EXECUTIVE OFFSHORE
(09/16 Rev 2)
RECORD OF SEA SERVICE
RECORD OF SEA SERVICE

Engine No. of days of this operation Total

S/N Name of Company Name of Vessel Rank Vessel Type DP 1/ 2 /3 DP Make and GRT BHP Propulsion Type of Installation Served Trading Area Charterer From To Reason for Sign Off
Model
Make Model Supply Anchor Handling Towing Dive Support ROV Flotel MM/DD
1 ALAM MARITIM SETIA SAKTI Junior Engineer Trainee DSV DP 2 2996 CATERPILLER 2575 BHP CPP 73 Others Shell Sarawak 31/05/2018 12/8/2018 73 Completion of Contract
2 ALAM MARITIM SETIA ZAMAN Junior Engineer Trainee MPSV 481 Others 53 Others Shell Sarawak 30/08/2018 22/10/2018 53 Completion of Contract
3 ALAM MARITIM SETIA SAKTI Oiler DSV DP 2 2996 CATERPILLER 2575 BHP CPP 108 Others Shell Sarawak 18/12/2018 3/4/2019 106 Completion of Contract

Where did you get to know about Executive Ofshore (Please mark "Y" where applicable)
Contacted by EO staf

R. Security Self-Declaration