Download - MMA - Application Form (Latest)

# Form have to be completely filled with information and signed * Dates to be in entered in DD/MM/YY format

A.

B.

C.

D.

E.

F.

No DP System

1 NIL

2 NIL

3 NIL

4 NIL

5 NIL

6 NIL

7 NIL

8 NIL

9 NIL

10 NIL

11 NIL

12 DP-1

13 NIL

14 DP-1

14871AC879E81D2CTest Licence Code

Advance Fire Fighting (A-VI/3)

INDONESIA

04/12/12

YES

02/07/20

YES

02/07/156200073545060315

02/07/15

01/10/17

31/12/16

Revalidated (Yes or No)

Certificate Class

YUSRI TRIMAINI

YES

JAKARTA

N/A

PTSC VIETNAM,

CARIGALI PETRONAS

/ DULANG OIL FIELD

JASMIN OIL FIELD

MUBADALA,

SATTAHIP GULF OF

AHTS

Jaya Offshore Pte Ltd Singapore


05/08/2011

19/02/2012MASTER

AHTS

2005..

Singapore

Singapore

Anchor Handling,Rig

Move,Towing, Static

Tow.Lifting Tanker,

Jaya Base

Anchor Handling,Rig

Move,Towing, Static

Tow.Lifting Tanker, Anchor Handling,Rig

Move,Towing, Static

Tow.Lifting Tanker,

Singapore

Anchor Handling, Rig

Move,Towing , Static Tow,

Lifting Tanker (PTSC

Delivery new ship from

Guangzou china


yue xien china China, Singapore

JASMIN OIL FIELD

MUBADALA,

SATTAHIP GULF OF JASMIN OIL FIELD

MUBADALA,

SATTAHIP GULF OF

THAILAND

PERTAMINA

TONGKANG, JAVA

SEA , MADURA OIL

JAYA BASE SINGAPORE

JASMIN OIL FIELD

MUBADALA,

SATTAHIP GULF OF JASMIN OIL FIELD

MUBADALA,

SATTAHIP GULF OF

16/02/2007

Singapore

Singapore

Singapore

20/08/2005Chest boat, running

cargo, supply boat.


Guangzou china

19/06/2006

25/09/2006

INDIA, DEEP DRILLER,

MYANMAR YANGON.

China, Singapore

China, Singapore

Anchor Handling,Rig

Move,Towing, Static

Tow.Lifting Tanker,

Maintenance Platform,

Date of Availability* ANYTIME

INDONESIA

F (14), F (11), M (8)

28/09/1528/10/14

Wartsila MASTERBunker Barge Malaysia,

Singapore.

Bunker Barge, Malaysia,

Singapore.M'SIA

NO

YES

2005..

Tanjung Balai Karimun Drug & Alcohol Date*

04/09/20

2010

Working Shoe Size

Year (e.g 1990 - 1995)

XXL

Passport Expiry Date*

Seaman Book Expiry*

Medical History (if any)

23/05/18

11

Home Telephone No. + 62 81372337244

Hindun Deceased (Yes or No) Father's Name & Age H.M.SYAICHU Deceased (Yes or No) YES

Name of Spouse

N/A

N/A

02/02/2011

14/09/2011

Rank in DPDP1/DP2/D

P3

6200073545080315 02/07/15

Singapore

Singapore

Singapore

2005..

2005..

Anchor Handling,Rig

Move,Towing, Static

Tow.Lifting Tanker,

10/01/2003

02/05/2006

06/10/2004

Ch.Ofc

24/09/2006

MV.DJM FORTUNE 3

MV.JAYA AMANDAM

MASTER

Caterpillar

Caterpillar

Caterpillar

Wartsila

617

1204

1204

1459

214

ISM Code

30/11/2004

19/05/16

19/05/16

23/09/17

Signed

Off*

29/09/17

23/09/14

Helicopter Landing Officer (HLO)

HUET

939257072008144000

RankSigned

On*

M'SIA

Description of Certificate

Unlimited Full DP Certificate

DP Basic (Induction)

26/08/2002

BASIC TRAINING FOR OIL AND CHEMICAL TANKER

Ship's Crane Operator

YES

30/06/20

MV.JAYA PUFFIN 5

MV.DJM FORTUNE 3

MV.MARINA

MV.JAVA CHALLENGER

MVJAYA SUPPLIER 3

MV. SEA INTREPID

MV. JAYA PUFFIN 3

MV.DJM FORTUNE 3

Supply

Utility

AHTS

AHTS

1204

AHTS

AHTS

AHTS

Detroit

61100789DI

2300

DP OPERATOR SKILL RETENTION&ENHANCEMENT TRAINING 08/03/14








1459

AHTS

AHT

AHTS

AHTS

Radar & ARPA

APPLICATION FOR THE POSITION OF: MASTER

CURRICULUM VITAE (CV)

Contact No. 2

Nationality & Race

SURABAYA

24/04/70

Contact No. 1MUHAMMAD IRHASJ HARIS

PERSONAL DATA

N/A

INDONESIAN & MALAY

Name (Exactly As in Passport)

Place of Birth

Date of Birth*

+ 62 81372821236

MV.DJM FORTUNE 3

MVJAYA MARINER 2

MV.JAYA AMARA



Jaya Offshore Pte Ltd Singapore 1

Caterpillar

Wartsila

Wartsila

18/04/2010

Anchor Handling,Rig

Move,Towing, Static

Tow.Lifting Tanker,

12/04/200912/04/2007

14/04/2009

11/10/2010

Singapore

Singapore

Singapore

Caterpillar

Caterpillar

1470

1470

1204

1491

Ch.Ofc

21/08/2005

Ch.Ofc

Ch.Ofc 2005..

11/11/2005

Caterpillar

Caterpillar

Religion

SINGAPORE

MALAYSIA

Medical Certificate Expiry*

married

+ 62 81261625756

Gender & Age

26/12/17

3

Same as Above address

No. of Children

N/A

Issued Date*23/09/10

04/08/15

COE-D0118896

YUSRI TRIMAINI

MOESLEM

23/06/1723/06/2015

16/09/15

Expiry Date*

N/A

31/12/16

Wartsila

02/07/20

Certificate No.

855

02/07/20

02/07/20

YES

Flag

LOCAL OWNER, PORT

KLANG, MALAYSIA

Country of Issuance

INDONESIA

INDONESIA

Relationship

02/07/20

Type and number of

offshore operations

carried out

13/01/2003MASTER

DP ADVANCED / S694/12

MASTER UNLIMITED

CLASS 1 (ONE) 6200073545N10210

6200073545N10210

Tanker

Type of VesselEngine

Type

02/07/20 YES

Expiry Date*

YES

YES

Issued Date*

19/11/15

Date Due for Revalidation*

Limitations Applying (if any)

N/A

WIFE

Singapore COE SINGAPORE

National GMDSS / GOC

National GMDSS / GOC Endorsement

Jl. Bangka Komplek Timah D. 79, RT 002, RW 005, Teluk Uma, Tanjung Balai Karimun, Indonesia

Country of Issuance

INDONESIA

INDONESIA

Contact No.

Major

BP3IP, JAKARTA

MT.AROWANA 2 BHL, Malaysia

GRTCompany & Country

6200073545210312

Ship Security Officer (A-VI/5 & B/VI-5)

Vessel Name

CERTIFICATE OF COMPLETION

CLASS 1 (ONE)

A1,A2,A3 and A4

N/A


Basic Safety Training (A-VI/1-1 to 1-4)

SEA SERVICES RECORD AS IN SEAMAN BOOK. INDICATE

MAXIMUM

Azimuth Thruster 360 Deg.

COURSE ATTENDED & CERTIFICATES OBTAINED

Certificate No

6200073545030315

Basic Firefighting (A-VI/1-2) N/A

Medical Care On Board (A-VI/4-2)

6200073545040315

26/12/12

EDUCATIONAL BACKGROUND

Highest Qualification Attained

National Certificate of Competency

National Certificate of Competency Endorsement

02/07/15 02/07/20

Personal Survival Techniques (A-VI/1-1) 6200073545010315 02/07/15 02/07/20

Elementary First Aid (A-VI/1-3)

Issued Date*

N/A

6200073545010315

N/A

Marlins Test Score 83% Test Location

MARINE TECHNOLOGIES SINGAPORE

Charter & Areas

of Operations

THE DP CENTRE, SINGAPORE

02/07/15

YES

YES INDONESIA

NO

INDONESIA

Personal Safety & Social Responsibility (A-VI/1-4) N/A

Country of Issuance

LONDON,UK

INDONESIA

04/03/2004/03/15 YES INDONESIA

INDONESIA

INDONESIA

02/07/15 02/07/10 YES INDONESIA

20/08/14 19/08/18

27/03/99

10/01/13 10/01/18

02/07/15

N/A

LOCAL OWNER, PORT

KLANG, MALAYSIA

13/12/12


Expiry Date*

19/11/20

MSA, Malaysia

MUST BE TRUE and HONEST in SEA SERVICES and Previous RANK - SEA TIME STATED BELOW MUST BE THE SAME WITH SEAMAN BOOK & DP LOGBOOK

19/05/11DP BASIC / S245/11

MASTER

MASTER

MASTER

Ch.Ofc

Ch.Ofc

Ch.Ofc

Current Salary in USD

International Passport No.

Seaman Book No.

[email protected] ID

Working Coverall Size

Body Weight in KG

Medical Certificate Issue Date*

Email Address

Expected Salary in USD

B 1240537

Y 041579

85 Height in CM 178

N/A

Main Airport Name

Marital Status

DP CERTIFICATION

2. 055 /ISM/BPLP SMG./III/99

Certificate No

26984

Limited DP Certificate

DP Advance (Simulator)

Next of Kin Name (Emergency)

Security Awareness Training (A-VI/6-1)

6200073545280313

Next of Kin Address


Highest School Attended

Mother's Name & Age

Home Address

CERTIFICATE OF COMPETENCY

COE-R0063809Singapore GOC

Malaysia COR

6200073545240315

Security Training for Seafarers with Designated Security Duties (A-VI/6)

Medical First Aid On Board (A-VI/4-1) 6200073545070315

13/01/2011

1

6200073545230315 02/07/15 02/07/20

N/A

Bridge Resource Management (A-II/2)

ECDIS (A-II/1 & A-II/2)

6200073545390315

30/06/15

02/07/15

INDONESIA

Survival Craft & Rescue Boat (A-VI/2 para 1-4)

Fast Rescue Craft (A-VI/2 para 5-8)

N/A

N/A

NO

6200073545020315

BOSIET / FOET

INDONESIA

Radar Observer INDONESIA

INDONESIA

OIL TANKER SPECIALIZED TRAINING PROGRAMME 6200073545100315 02/07/15 02/07/20 YES INDONESIA

NO

INDONESIARIGGING,SLINGING AND LIFTING TRAINING

IMDG CODE

H2S

6200073545290315

INDONESIA

NO

H2S.00735/OTM/2014

RSLT.00733/OTM/2014

29/09/14

INDONESIA

FWM 2/23/20167:32 PM

mailto:[email protected]

15 DP-1

16 DP-1

17 DP-1

18 DP-1

19 AHTS DP-1

20 DP-2

21 DP-2

22 NIL

23 DP-1

G. H.

No

1

2

3

4

5

Towing, Rig Move, Anchor

Handling, Maintenace

platform, Running Cargo,

Drilling Support, Seismic

Seismic Support

MURPHY OIL

MALAYSIA WEST

PATRICIA OILFIELD

BINTULU SARAWAK /

PETRONAS CARI GALI,

CGG Baram Field,

Ch.Off JDPO

MASTER

Ch.Off JDPO 06/01/2015

25/02/2015

19/01/2016

05/07/2015

Labuan

SingaporeDJM FORTUNE 3


MERMAID MARINE AUSTRALIA PTE.LTD

AHTS

AHTS

2 3607

1204

Towing, Rig Move, Anchor

Handling, Maintenace

platform, Running Cargo,

Drilling Support, Seismic

MURPHY OIL

MALAYSIA WEST

PATRICIA OILFIELD

BINTULU SARAWAK /

JAYA AMANDAM Jaya Offshore Pte Ltd Singapore 1 1459

SEA HAWK 1 Jaya Offshore Pte Ltd Singapore AHTS 2 2952 Wartsila Ch.Off JDPO Ch.Off JDPO 21/10/2014

20/03/2014

MUHAMMAD IRHASJ HARIS

10/12/2015

28/01/2013

01/10/2013

18/09/2015

20/06/2014 Singapore

Anchor Handling,Rig

Move,Towing ,


Running Cargo, Drilling

BSP (BRUNEI SHELL

PETROLEUM),

BRUNEI OILFIELDS

CHAMPION,AMPA,

Drilling Support,


Running Cargo

Singapore

Singapore

Anchor Handling,Rig

Move,Towing ,

Maintenance Platform, Anchor Handling,Rig

Move,Towing ,

Maintenance Platform, Anchor Handling,Rig

Move,Towing ,


Running Cargo, Drilling Anchor Handling,Rig

Move,Towing ,





AHTS

AHTS

AHTS

Singapore

BSP (BRUNEI SHELL

PETROLEUM),

BRUNEI OILFIELDS Jaya Offshore Pte Ltd Singapore

AHTS

BSP (BRUNEI SHELL

PETROLEUM),

BRUNEI OILFIELDS

CHAMPION,AMPA, BSP (BRUNEI SHELL

PETROLEUM),

BRUNEI OILFIELDS MASTER

MASTER

BSP (BRUNEI SHELL

PETROLEUM),

BRUNEI OILFIELDS

23/04/2012 Singapore

Singapore

MASTER

MASTER

MASTER

1458

1458

1459

Wartsila

Wartsila

Wartsila

1458

02/10/2012

06/01/2015 Labuan

MV.JAYA AMETHYST

MV.JAYA AMETHYST

MV.JAYA AMETHYST

JAYA AMANDAM

PETRONAS. Yetagun

Field, Myanmar.

30/08/2012

10/12/2012

10/06/2013

11/01/2014

1458

CaterpillarMERMAID MARINE AUSTRALIA PTE.LTD MASTER

Wartsila

Wartsila

Date*

DECLARATION

I hereby declare that the information furnished above is true to the best of my knowledge.

Contact NumberName of Company Name of Contact Person Email

AHTS

1

1

1

1

1

Caterpillar

Wartsila

JAYA ALMIGHTY

JAYA MAJESTIC

REFERENCES

Signature

FWM 2/23/20167:32 PM

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14871AC879E81D2C

INDONESIA

4750

3500

4750

1200

5150

4800

5150

ANYTIME

INDONESIA

F (14), F (11), M (8)

04/09/20

2010

23/05/18

11

+ 62 81372337244

YES

N/A

Finished

Contract

Finished

Contract

4750

Rec

ent P

hoto in

JPEG

(Com

pulsory

)

N/A

INDONESIAN & MALAY

+ 62 81372821236

4000

4800

Finished

Contract

4000

SINGAPORE

MALAYSIA

+ 62 81261625756

MOESLEM

23/06/17

3200Finished

Contract

Country of Issuance

INDONESIA

INDONESIA

Finished

Contract

Finished

Contract

Transfer Ship

Transfer Ship

Transfer Ship

N/A

WIFE

SINGAPORE

Country of Issuance

INDONESIA

INDONESIA

MARINE TECHNOLOGIES SINGAPORE

BHP/K-WATT


Reason For

Leaving

INDONESIA

INDONESIA

Country of Issuance

LONDON,UK

Finished

Contract

INDONESIA

INDONESIA

INDONESIA

INDONESIA

INDONESIA



3400

Transfer Ship

Finished

Contract

4750

Transfer Ship

Transfer Ship

INDONESIA

INDONESIA

INDONESIA

INDONESIA

INDONESIA

INDONESIA

INDONESIA

INDONESIA

FWM 2/23/20167:32 PM

12070

4750

Finished

Contract

Finished

Contract

12070 Transfer Ship

4800

5150

Finished

Contract

4800

4800

4800

4800

Finished

Contract

Finished

Contract

Finished

Contract

Finished

Contract

Finished

Contract

Date*

DECLARATION


FWM 2/23/20167:32 PM


A.

B.

C.

D.

E.

F.

No DP System

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

G.

1 2 3 4 5

6 7 8 9 10

H. I.

No

1

2

3

4

5

Place of Birth Contact No. 2

Date of Birth* Nationality & Race

APPLICATION FOR THE POSITION OF:

Rec

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JPEG

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pulsory

)


PERSONAL DATA

Name (Exactly As in Passport) Contact No. 1

International Passport No. Passport Expiry Date*

Seaman Book No. Seaman Book Expiry*

Current Salary in USD Expected Salary in USD Date of Availability*

Working Coverall Size Working Shoe Size

Body Weight in KG Height in CM Religion

Medical Certificate Issue Date* Medical Certificate Expiry*

Email Address Skype ID Medical History (if any)

Main Airport Name Drug & Alcohol Date*

Marital Status Name of Spouse No. of Children Gender & Age

Mother's Name & Age Deceased (Yes or No) Father's Name & Age Deceased (Yes or No)

Next of Kin Address Contact No.


Home Address Home Telephone No.

Next of Kin Name (Emergency) Relationship

Marlins Test Score Test Location Test Licence Code

Highest School Attended Year (e.g 1990 - 1995)

Highest Qualification Attained Major


Description of Certificate Certificate Class Certificate No. Issued Date* Expiry Date* Limitations Applying (if any) Country of Issuance

National Certificate of Competency Endorsement

National Certificate of Competency

National GMDSS / GOC Endorsement

National GMDSS / GOC

Singapore GOC

Singapore COE


COURSE ATTENDED &

CERTIFICATES OBTAINED

Description of Certificate Certificate No Issued Date* Expiry Date* Revalidated (Yes or No) Country of Issuance

Malaysia COR

Basic Firefighting (A-VI/1-2)

Personal Survival Techniques (A-VI/1-1)

Personal Safety & Social Responsibility (A-VI/1-4)




Medical First Aid On Board (A-VI/4-1)

Advance Fire Fighting (A-VI/3)

Ship Security Officer (A-VI/5 & B/VI-5)

Medical Care On Board (A-VI/4-2)



Maintenance of Electrical & Electronics Equipment

Engine Room Resource Management

BOSIET / FOET

High Voltage Certificate

H2S

HUET

Any other certs (please indicate)

DP CERTIFICATION

Description of Certificate Certificate No Issued Date* Expiry Date* Date Due for Revalidation* Country of Issuance

Azimuth Thruster 360 Deg.

DP System Maintenance

SEA SERVICES RECORD AS IN

SEAMAN BOOK. INDICATE

MAXIMUM


Vessel Name Company & Country Type of VesselDP1/DP2/D

P3GRT

Engine

TypeRank BHP/K-WATT

Reason For

Leaving

Signed

On*

Signed

Off*Flag

Type and number of

offshore operations

carried out

Charter & Areas

of Operations

INDICATE SOME ENGINE MODEL

NUMBER.EXAMPLE OF ENGINE MODEL AS BELOW

Remarks

REFERENCES DECLARATION

Name of Company Name of Contact Person Email Contact Number

Signature Date*


FWM 2/23/20167:32 PM


A.

B.

C.

D.

E.

No

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

F.

1 2 3 4 5

6 7 8 9 10

G. H.

No

1

2

3

4

5




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PERSONAL DATA





















COURSE ATTENDED &



Watchkeeping COC for Ratings











HUET

BOSIET / FOET

Ship's Crane Operator

H2S

Helicopter Landing Officer (HLO)




MAXIMUM


Vessel Name Company & Country Type of VesselDP1/DP2/D

P3GRT

Engine

TypeRank BHP/K-WATT

Reason For

Leaving

Signed

On*

Signed

Off*Flag

Type and number of

offshore operations

carried out

Charter & Areas

of Operations

INDICATE SOME ENGINE MODEL

NUMBER.EXAMPLE OF ENGINE MODEL AS BELOW

Remarks

REFERENCES DECLARATION


Date*


Signature

FWM 2/23/20167:32 PM


A.

B.

C.

D.

E.

No

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

F. G.

No

1

2

3

4

5




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PERSONAL DATA





















Training Couse for Ship's Cook

Certificate of Competency for Cook

Maritime Catering

Food Handling & Hygiene

COURSE ATTENDED &



Any other certificates (please indicate)











HUET

BOSIET / FOET


H2S

BHP/K-WATTReason For

Leaving

Signed

On*

Signed

Off*Flag

Type and number of

offshore operations

carried out

Charter & Areas

of OperationsVessel Name Company & Country Type of Vessel

DP1/DP2/D

P3GRT

Engine

TypeRank


REFERENCES



MAXIMUM


Signature Date*


DECLARATION

FWM 2/23/20167:32 PM