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Application Form: PT Jasindo Duta Segara

This document is an application form for a position as a seafarer with PT Jasindo Duta Segara. It requests personal information such as name, date of birth, education history, certifications, sea service experience, English language ability, and a signed acknowledgement. The form collects details on formal education, certificates of competency and proficiency, passport, seaman book, previous vessel experience including rank, routes sailed, tonnage, ship type, companies worked for, salary and reasons for leaving. Other areas of inquiry include drug/alcohol use, uncompleted contracts, foreign vessel experience and qualifications in writing, speaking and reading English.

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121 views2 pages

Application Form: PT Jasindo Duta Segara

This document is an application form for a position as a seafarer with PT Jasindo Duta Segara. It requests personal information such as name, date of birth, education history, certifications, sea service experience, English language ability, and a signed acknowledgement. The form collects details on formal education, certificates of competency and proficiency, passport, seaman book, previous vessel experience including rank, routes sailed, tonnage, ship type, companies worked for, salary and reasons for leaving. Other areas of inquiry include drug/alcohol use, uncompleted contracts, foreign vessel experience and qualifications in writing, speaking and reading English.

Uploaded by

obhetz
Copyright
© © All Rights Reserved
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
Download as xls, pdf, or txt
Download as xls, pdf, or txt
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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
[email protected] ; 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.

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