Deck Cadet Android

APPLICATION FORM

Date of Readiness : . . . (DD.MM.YYYY)

Name (in full) Rank Vessel

PHOTO

DIMAS LAKSMANA PERMADI DECK CADET

Place & Date of Birth : BANJARBARU / 22 DECEMBER 1994 Height : 173 cm Province : SOUTH BORNEO Weight : 65 kg

Marital Status : SINGLE Blood Type : B

Children : FIRST Clothe's Size : L

Religion : MOSLEM Shoes Size : 42

Address : NANAS STREET NO 1 BLOK H PALANGKARAYA, CENTRAL BORNEO Pos Code 73111

Contact Person : *************@*****.*** Telp. / HP : 085********* Education

Formal Place Year Remark

1 Senior High School PALANGKARAYA 2013 SMAN 2 PALANGKARAYA 2 Maritime Education SEMARANG NOW STIMART AMNI SEMARANG Certificate of Competency:

Grade STCW '95 Place and Date of Issued Expire Date Number of Certificate 1 BRIDGE SIMULATOR SEMARANG,SEPTEMBER 17-201*-********* 2 ISM CODE SEMARANG,JUNE 2016 00929/STIMART "AMNI"/SO/V/2016 Certificate of Proficiency

Type Y / N Place and Date of Issued Expire Date Number of Certificate 1 BST Y SEMARANG,20 FEBRUARY 2015 20 FEBRUARY 2020 6211506577010315 2 MFA Y SEMARANG,09 JUNE 2015 09 JUNE 2020 6211506577070315 3 AFF Y SEMARANG,02 SEPTEMBER 2015 02 SEPTEMBER 2020 6211506577060315 4 RADAR Y SEMARANG,29 SEPTEMBER 2015 29 SEPTEMBER 2020 6211506577031215 5 ARPA Y SEMARANG,25 NOVEMBER 2015 25 NOVEMBER 2020 6211506577021215 6 SAT Y SEMARANG,03 NOVEMBER 2016 03 NOVEMBER 2021 6211506577310316 7 SDSD Y SEMARANG,04 NOVEMBER 201604 NOVEMBER 2021 6211506577320316 8 BOCT Y SEMARANG,08 NOVEMBER 201608 NOVEMBER 2021 6211506577390316 9 BLGT Y SEMARANG, 25 NOVEMBER 201625 NOVEMBER 2021 6211506577370316 DOCUMENT

TYPE Place and Date of Issued Expired Lisence Number 1 PASSPORT SEMARANG,15 DECEMBER 2016 15 DECEMBER 2021 B5449146 2 SEAMAN BOOK CILACAP,26 NOVEMBER 2016 26 NOVEMBER 2019 E129148 Others

Other skilled : Uncompleted Working Contract : Vessel Drug/alkohol Drink : NO 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.