PT. Rizki Karya Samudera
Manning Crew Agency
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Bulk Carrier Application Form
BULK CARRIER APPLICATION FORM
Applied For The Position Of
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Age
Date of readiness
*
Surname
Forename
Father`s Name
Mother`s Name
Date Of Birth (Exp: dd-mm-yyyy)
Place Of Birth
Marital Status
Single
Married
Nationality
Education
Home Address
Crew Phone Number
Emergency Phone Number
Email
Skype
Next Of Kin
Surname
Forename
Home Address
Dependants (number):
Sons
Daughter
Fill Out All Documents
Document Type
Travel Passport US visa (expiry date)
Travel Passport Schengen visa (expiry date)
Seaman’s book
S T C W Endorsement/ COC
Medical Fitness Certificate
Yellow Fever Vaccination
Numbers
Issuing Authority
Director General of Sea Transportation
Other
Date Issued
Expiry Date
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QUALIFICATIONS
Fill Out All Qualifications
Certifications
Certificate of Competence / License
Deep Sea Captain (A-II/2)
Deep Sea Navigator (A-II/2)
Navigator, Short Voyages Navigator (A-II/1)
Boatswain, 1st Cl. Seaman, 2nd Cl. Seaman (A-II/4)
Able Seafarer Deck (A-II/5)
3rd Cl. Engineer (A-III/1)
Chief Engineer, 2nd Engineer (A-III/2)
1st Cl. Mtm, 2nd Cl. Mtm, Oiler, Wiper (A-III/4)
1st Cl. Mtm, Able Seafarer Engine (A-III/5)
1st/ 2nd/ 3rd Cl. Electro Technical Officer (A-III/6)
Electrician (A-III/7)
GMDSS radio operators A-IV/2
Basic training A-VI/1-1 to 1-4
Proficiency in surv.craft & RB other than FRB A-VI/2-1
Advanced fire fighting A-VI/3-1
Medical care A-VI/4-1,2
Ship Security Officer A-VI/5
Security Awareness for Seafarers without Designated Security Duties A-VI/6-1
Security Awareness for Seafarers with Designated Security Duties A-VI/6-2
ECDIS (generic)
ECDIS (type specific: Furuno, JRC, Transas, Other)
Other Certificate
Are You Qualified
Yes
No
Issuing Authority
Director General of Sea Transportation
Other
Date Issued
Expiry Date
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OTHER CERTIFICATE
Fill Out Other Certifications
Certifications
Certificate of Competence / License
Deep Sea Captain (A-II/2)
Deep Sea Navigator (A-II/2)
Navigator, Short Voyages Navigator (A-II/1)
Boatswain, 1st Cl. Seaman, 2nd Cl. Seaman (A-II/4)
Able Seafarer Deck (A-II/5)
3rd Cl. Engineer (A-III/1)
Chief Engineer, 2nd Engineer (A-III/2)
1st Cl. Mtm, 2nd Cl. Mtm, Oiler, Wiper (A-III/4)
1st Cl. Mtm, Able Seafarer Engine (A-III/5)
1st/ 2nd/ 3rd Cl. Electro Technical Officer (A-III/6)
Electrician (A-III/7)
GMDSS radio operators A-IV/2
Basic training A-VI/1-1 to 1-4
Proficiency in surv.craft & RB other than FRB A-VI/2-1
Advanced fire fighting A-VI/3-1
Medical care A-VI/4-1,2
Ship Security Officer A-VI/5
Security Awareness for Seafarers without Designated Security Duties A-VI/6-1
Security Awareness for Seafarers with Designated Security Duties A-VI/6-2
ECDIS (generic)
ECDIS (type specific: Furuno, JRC, Transas, Other)
Other Certificate
Are You Qualified
Yes
No
Issuing Authority
Director General of Sea Transportation
Other
Date Issued
Expiry Date
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EXTRA SKILLS / CERTIFICATE
Field Out Extra Skills/Certificates
Extra Skills / Certificate
Are You Qualified
Yes
No
Issuing Authority
Director General of Sea Transportation
Other
Date Issued (dd-mm-yyyy)
Expiry Date (dd-mm-yyyy / Unlimited)
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PREVIOUS SEA SERVICE (STARTING FROM THE LAST CONTRACT)
PREVIOUS SEA SERVICE (Starting from the last contract)
SHIP’S NAME/ FLAG/ YEAR OF BUILD
Type/Dwt
ME TYPE MAKER/ MODEL/KW
DECK CRANES: TYPE, MAKER, S.W.L. (*)
OWNER/ SHIPMANAGEMENT
CONTACT DETAILS
RANK
Service Time DATE ON
Service Time DATE OFF
REASON OF SIGN-OFF
TOTAL SERVICE ONBOARD
(*) – FOR CH.ENGINEER, EL.ENGINEER, ELECTRICIAN TOTAL EXPERIENCE WITH DECK CRANES:
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Overall`s Size
Shoes`s Size
Weight
Height
APPLICANT (NAME):
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