Norwegian Cruise Line Ltd.

2nd floor - Mountbatten House

Southampton, SO15 2JU
United Kingdom

NORWEGIAN CRUISE LINE APPLICATION FORM

1. PERSONAL DETAILS
Surname: Pida First name: Muliadi Job Application no: NCL.03.21
Date of birth: 07 July 1976 Place of birth: Pinrang - Indonesia Nationality: Indonesian
Permanent Address: Laladon Baru Residence Blok F No 12a. Kel Laladon. Kec Ciomas- Kab Bogor, Jawa Barat-
Indonesia. 16610
Phone No: +62 - 81312610804 WhatsApp No: +62-81312610804 Email: [email protected]

2. GENERAL DETAILS
Document Number Date of issue Place of Date of
issue Expire
Passport C 7444654 06 April 2021 Bogor – 06 April 2026
Insonesia
Seaman’s Book E 125660 07 Sept 2016 Jakarta 29 Sept 2024

3. CERTIFICATES / QUALIFICATIONS
Grade/Class Number Date of issue Place of Date of
issue expire

Certificate of II/2.1 STCW 2010 / Class II 6200026607 14th Feb Jakarta - Unlimited
Competency: N20120 2020 Indonesia
GOC/ GMDSS: IV/2 STCW 2010 / GMDSS 6200026607 23rd March Jakarta - 23rd March
GA0120 2020 Indonesia 2025

4. EDUCATIONS
Date from Date to Marine Academy (College) Certificates Obtained
Jan 1994 09 Jan 1997 Barombong Marchant merine college Marine Interisland Certificate
Oct 2001 Nov 2001 Jakarta Marchant Marine Institute DOC - Class IV
Dec 2014 Dec 2015 Jakarta Marchant Marine Institute DOC - Class III
Feb 2019 Feb 2020 Jakarta Marchant Marine Higher DOC – Class II
education

5. ATTENDED DETAILS OF COURSES

Course No of Certificate Date of issue Place of issue Date of expire

Basic Safety Training (STCW VI/1) 6200026607011119 28th Feb 2019 Jakarta 28th Feb 2024
Advanced Fire Fighting 6200026607061117 27th Jan 2017 Jakarta 27th Jan 2022
Survival Craft & Rescue Boats 6200026607041119 28th Feb 2019 Jakarta 28th Feb 2024
Medical First Aid 6200026607071117 08th Feb 2017 Jakarta 08th Feb 2022
Medical Care 6200026607081117 30th Jan 2017 Jakarta 30th Jan 2022
SSO (ISPS Code) 6200026607241110 06th Feb 2019 Jakarta 06th Feb 2024
Radar Observation 6200026607031117 22nd Feb 2017 Jakarta 22nd Feb 2022
ARPA 6200026607021117 21st Feb 2017 Jakarta 21st Feb 2024
Hazmat for US
Dangerous Goods 6200026607290120 05th Feb 2020 Jakarta 05th Feb 2025
 Electronic Charts (ECDIS) 6200026607281119 05th March 2019 Jakarta 05th March 2024
Crowd Management Training

6. Flagstate seaman’s book (even expired)

State No of SBK Date of issue Place of issue Date of expire
Indonesian E 125660 07 Oct 2016 Jakarta 29th Sept 2022
Bahamas SRB364705 23rd May 2016 Bahamas
Cyprus CY211984 11st Sept 2013 Cyprus 10th Sept 2023

7. MEDICAL FITNESS
Date of issue Place of issue Date of expire
Health Certificate 398 /MCU/PRIVATE / OLMC / XI / 12nd 2020 Jakarta 12nd Nov 2022
20
Yelow Fever C00-0490698 20th Dec 2012 Jakarta 20th Dec 2022

8. PERSONAL DATA
Color of Eyes Color of Hair Height Weight Size of Overall Size of shoes
Black Black 170 Cm 81 Kg 52 (XL) 42

9. KNOWLEDGE OF LANGUAGES
(Indicate the level of your languages skills (3 = fluent, 2 = business, 1 = passable, 0 = very limited or none at all)
Speaking Reading Writing
English 2 2 2
German 0 0 0
Spanish 0 0 0
Danish 0 0 0
Other Bahasa Bahasa Bahasa

10. MARITAL STATUS: married, single, divorced, separated, widowed

Marital status: Married
Spouse Full Name: Nisful Lily
Address, Phone: + 6281219304990
Number of children under 18 y.o: One

11. CONFIDENTIAL INFORMATION FOR OFFICE USE ONLY

Full Name of Next of Kin: Nisful Lily Relationship:
Address of Next of Kin: Laladon Baru Residence Blok F No 12a. Desa Laladon- Wife
Kecamatan Ciomas – Kabupaten Bogor – Jawa Barat – Indonesia. 16610

12. SEA SERVICE (for last 10 years)

KWT
FROM: TO: Blt Owner or
Name of ship Flag GRT Engine Type of ship Rank
dd.mm.yy dd.mm.yy yyyy Managers
type
05.08.2022 05.11.2022 SL Puma 2011 Cyprus 684 6530 ASD tug Tug master Smit lananalco
15.05.2021 28.05.2022 SL Jaguar 2009 Bahamas 684 5420 ASD Tug Tug Master Smit Lamnalco
01.03.2020 22.09.2020 SL Tiger 2012 Cyprus 653 5050 ASD tug Tug master Smit lamnalco
24.06.2019 22.08.2019 SL Puma 2011 Cyprus 684 6530 ASD tug Tug master Smit lananalco
24.01.2019 16.05.2019 SL Jaguar 2008 Bahamas 684 5420 ASD Tug Tug Master Smit Lamnalco
02.05.2018 19.12.2018 SL Tiger 2012 Cyprus 653 6530 ASD Tug Tug Master Smit Lamnalco
19.12.2017 21.03.2018 SL Serval 2012 Cyprus 653 6772 ASD Tug Tug Master Smit Lamnalco
10.07.2017 10.11.2017 SL Martinique 2008 Bahamas 594 4200 ASD Tug Tug Master Smit Lamnalco
21.02.2017 24.05.2017 SL Tiger 2012 Cyprus 653 6530 ASD Tug Tug Master Smit Lamnalco
09.10.2016 20.01.2017 Lamnalco Egret 2008 Cyprus 784 4900 ASD Tug Tug Master Smit Lamnalco
23.05.2016 10.09.2016 SL Jaguar 2008 Bahamas 484 5420 ASD Tug Tug Master Smit Lamnalco
21.09.2015 07.04.2016 Lamnalco Aden 2009 Pakistan 724 8600 AHTS Tug Master Smit Lamnalco
14.02.2015 30.09.2015 SL Sphere 2007 Liberia 246 3600 ASD Tug Tug Master Smit Lamnalco
15.08.2014 15.01.2015 SL Nida 2008 Liberia 484 5050 ASD Tug Tug Master Smit Lamnalco
05.01.2014 03.07.2014 SL Nida 2008 Liberia 484 5050 ASD Tug Tug Master Smit Lamnalco
11.09.2013 26.11.2012 SL Manakin 2010 Limassol 1290 AHTS Chief Officer Smit Lamnalco
23.12.2012 13.07.2012 SMIT Nida 2008 Liberia 484 5050 ASD Tug Tug Master Smit Lamnaco
 Tangguh
BP LNG
18.05.2012 15.12.2012 Mangiwang / 2010 Indonesia 481 5420 ASD Tug Tug Master
Tangguh
Pangguh Ewako
Tangguh Garopa / BP LNG
10.11.2011 20.02.2012 2010 Indonesia 481 5420 ASD Tug Tug Master
Tangguh Pauru Tangguh
10.08.2011 12.10.2011 KST Super 2008 Singapore 246 3600 ASD Tug Tug Master Smit Singapore
26.01.2011 21.07.2011 Smit Cyman 2009 Singapore 294 4200 ASD Tug Tug Master Smit Singapore
02.01.2010 18.12.2010 KST Super 2008 Singapore 246 3600 ASD Tug Tug Master Smit Singapore
12.07.2009 10.12.2009 Smit Monserrat 2009 Singapore 294 4200 ASD Tug Tug Master Smit Singapore
04.02.2009 15.06.2009 KST Super 2008 Singapore 246 3600 ASD Tug Tug Master KST Singapore
15.03.2008 15.01.2009 Kejora enam 2005 Malaysia 290 3600 ASD Tug Tug Master KST Singapore
MT. Soechi Chemical PT. Soechi
04.11.2007 10.03.2008 1984 Indonesia 2904 Chief Officer
Chemical XIX Tanker lines
MT. Soechi Chemical PT. Soechi
20.12.2006 03.01.2007 1985 Indonesia 936 Master
Chemical III Tanker Lines
Chemical Sokuyu
29.10.2005 28.02.2006 MT. Sun Queen 2003 Panama 2993 Chief Officer
Tanker Tankers
MT. Soechi Chemical PT. Soechi
14.12.2014 20.09.2005 1983 Indonesia 1002 Chieh Officer
Chemical V Tanker Lines
MT. Soechi Chemical PT. Soechi
11.02.2003 09.11.2004 1984 Indonesia 674 Chieh Officer
Chemical I Tanker Lines
PT. Puspa
10.06.2002 16.12.2002 MT. Mawarni 108 1984 Indonesia 1020 Oil Tanker Chief Officer Samudera
Permata
PT. Arung
15.02.2000 20.10.200 TB Gasindo 12 1998 Insonesia 246 2400 Towing tug Chief Officer
Samudera
General
15.01.1999 02.02.2000 KM. Bawadi 1990 Indonesia 2600 Chief Officer PT. JPL
Cargo
MT. Ochid PT. Ocean
06.11.1997 08.04.1998 1990 Singapore Tankers 2nd Officer
Chemical Marine
MT. Andhika Chemical PT. Andhika
16.08.1994 24.07.1996 Panama Cadet
Adhiraksha Tanker Lines
AVAILABLE FOR SERVICE FROM:
Note: Do not return this employment form without a passport photograph attached to it.