RYAN SHIP MANAGEMENT LTD

SHIPPING CONNECTIONS / (MARITIME RECRUITMENT)

POSTAL ADDRESS:-RYANSHIP P O Box – 1282 - SUNDERLAND
TYNE and WEAR SR5 9HX UNITED KINGDOM
Tel: +44 191 54 888 59 Fax: +44 191 54 88 425
Email : SHIPPINGCONNECT@aol.com www.shipping-connections.com

Application Form Deck / Engine / Catering Ratings

Section 1 Position
Position Applied for AB
Lowest Position Acceptable AB
Date of Availability 12 / 07 / 2010
Section 2 Personal Details
Family name / Surname EDEWAN
First Name / Given Name WALTER
Date & Place of Birth Date - 24 February 1977 Place- DUMAI
Nationality Indonesian
Permanent Address Perumahan Taman Sari Hijau, Blok G7 No. 16 Tiban – Batam
Indonesia
Present Address Perumahan Tiban Koprasi, Blok F No. 31 Tiban – Batam
Indonesia
PPE information SAFETY SHOES SIZE 40 COVERALL SIZE L

Present Contact Number +62811696505

Fax Number +62778326912
Mobile Number +6281364541674
Email Address walter_edewan@rocketmail.com
Nearest Airport HANG NADIM – BATAM
Section 3 Passport and VISA details
Country of Issue Indonesia USA Visa - Type B1/OCS
Date Issued 16 February 2010 USA VISA Expires -
Place Issued Batam USA Visa - Type C1/D
Passport Number U 594236 USA VISA Expires -
Passport –Expires 16 February 2015 Other Country Visa -
Secondary passport or Dual Visa Expiry -
nationality

Section 4 ( hi-light as required ) Seaman book / Discharge book / Seaman Record Book / CDC
Issuing Country & Place Batam - Indonesia Date Issued 01 February 2010
Number W 073322 Expiry Date (if any) 31 January 2013

Section 5 Next of Kin – this is important information we require- Don’t ignore it

Full Name / Relationship TURINO / FATHER
Any dependents / Children (incl age ) - / Daugther ( 1 Years )
Address Jl. Hayam Wuruk, GG Firdaus No.267, Dumai - Indonesia
Contact Numbers +6281371194668
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Section 6 STCW95 Highest Certificate of Competency / Licence Held ( also list Flag State Endorsements)

Class / Grade/Capacity STCW95 ISSUING CERTIFICAT DATE EXPIRY

CODE COUNTRY E No ISSUED

6200201414N Jakarta, -
Navigational Watch Rating CW05005111 Indonesia
60306 20/12/2016
Efficient Deck Hand
Engine Watch Rating
Cook Part 1
Cook Part 2
Other ????

Section 7 STCW95 Dangerous Cargo Familiarisation

Petroleum……………. STCW-95 Code Certificate No Issued Expires

Liquefied Gas………. A-V/1
Liquid Chemicals……. A-V/1
A-V/1

Section 8 STCW95 related Courses Attended and Certificates Obtained

Name of Course / Certificate STCW Code Place Issue Date Cert No Expiry
Date

Personal Survival Techniques A- VI/1-1

620020141401
Basic Sea Survival / Training A-VI/1 Jakarta 19/07/2006
0106
Fire Prevention & Fire Fighting A-VI/1-2
Elementary First Aid A-VI/1-3
Personal Safety & Social Responsibility A-VI/ 1-4
Proficiency in Survival Craft & Rescue 620019934304
Boats A-VI/ 2-1 Jakarta 07/08/2006
0106
Proficiency in RESCUE CRAFTS
Advanced Fire Fighting A-VI/ 3
Medical & First Aid A-VI/ 4-1
Ship Security Officers Course (SSO) A-VI/ 5
Issued under STCW95
Medical Certificate / HEALTH PM
Certificate 04.02/VIII/K Batam 24/05/2010 0524A
LN-UKLW
Drug and Alcohal test certificate Batam 24/05/2010 0524A
24/05/
YELLOW FEVER Batam 24/05/2010 0920924 2010
ISM Code A.1441 (18)
Hygiene Training
Crowd Control
Passenger Safety
MARLIN’s English Test
IELTS-English TEST http://www.ielts.org/test_centre_search/search_results.aspx SCORE
Section 9 OFFSHORE INDUSTRY COURSES
Fast Rescue Craft Coxswain
Daughter Craft Coxswain
Boatman Certificate
BOSIET Johor - Malaysia 26/09/2008 MY037135 25/09/2012
HUET Johor - Malaysia 26/09/2008 MY037135 25/09/2012
FOET
OFFSHORE MEDICALS
( UK, NORWAY or NETHERLAND )
Re-Breather training
Initial Standby vessel crews training ( ITSO )

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Section 9 OFFSHORE INDUSTRY COURSES- CONTINUED
Please enter below any other certificates held or courses done, ie offshore, DP certs etc or Any other not already mentioned
Name of Course / Certificate APPROVALS Place Issue Date Cert No Expiry

CAA (Civil Aviation Authorities –

Helicopter)
Advanced Medical Aider ( AMA )
HLO
HLA
Helicopter Refuelling

DEEP WATER ANCHOR HANDLING EXPERIENCE ENTER DEPTTH IN METERS 30 – 60 M

Section 10 Medical History

YES NO
Have you ever signed off a ship due medical reason ?
Have you undergone any medical operations in past ?
Have you consulted a doctor during the past 12 months for an illness / Accident
Do you have any health or disability problem now ??

If answer to any of above is YES then give further details below or on a separate sheet

NOTE : All our clients have STRICT Alcohol and Drug Policy, Which
means ZERO TOLERENCE for alcohol and drugs

Section 11 General

Yes No
Have you ever been the subject of a court of enquiry or involved in a maritime accident
Have you ever been convicted of any criminal offence?
Have you ever been dismissed

If yes to any of above then please full details below or on separate sheet of paper

Section 12 References (Last Two Recent Employers)

Name of company DRYDOCK WORLD
Name Person to be contacted Teguh Sriharyoso
Address Perumahan Villa Muka Kuning – Batam - Indonesia
Tel No +628127029141 Fax +62778391961
Email tasriek@drydocks-nanindah.com

Name of company DRYDOCK WORLD

Name Person to be contacted Teguh Sriharyoso
Address Perumahan Villa Muka Kuning – Batam - Indonesia
Tel No +628127029141 Fax +62778391961
Email tasriek@drydocks-nanindah.com

Section 13 Any other information, you wish to add in support of your application

Section 14 Declaration
I hereby declare that the above particulars are true and I authorize you to contact the referees listed above
And confirm that All my certificates / Licences are Authentic / SEASERVICE RECORD is ACCURATE / And I
confirm accepting Companies DRUG & ALCOHOL Policy

Signed : Date: 08 Juni 2010

Page 3 of 7

WALTER EDEWAN
Section 15 Record of Sea Service (All Dates to be entered as dd/mm/yy)
Please give full record of sea service STARTING FROM LAST VESSEL FIRST
VESSEL COMPANY Type of Vessel DWT GRT or BHP RANK Sign on DATE Sign off DATE
(please delete as reqd)
dd / mm / yy dd / mm / yy
SV. OCEAN
LABROY PTE.LTD AHTS 1030 7500 HP OS 05/12/2005 19/01/2007
GANNET
SV. OCEAN
LABROY PTE.LTD AHTS 1030 7500 HP AB 05/02/2007 09/02/2008
GANNET
SV. OCEAN
DRYDOCK WORLD AHTS 1030 7500 HP BOSUN 25/02/2008 23/12/2009
GANNET
Type of Engines :: for engineers only, DPOs to Mark DP System BHP : for Engineers and AHTS / TUG Masters & Officers Page 4 + 5 of 6
 ADDITIONAL INFORMATION SHEET
VESSEL TYPE YOU ARE INTERESTED IN (please list in order of priority)
1. AHTS
2.
3.
4.
5.
MAXIMUM ACCEPTABLE CONTRACT PERIOD (Please indicate below)
MINIMUM SALARY or DAY RATE EXPECTATION (please quote below in GBP£ (for
British Nationals) or in US$ (for NON-UK personnel)
Amount to enter below to be consolidated of any leave pay ( ie, inclusive of leave pay), Please
enter MINIMUM in order we can forward your CV for all offering above that ( please enter
Only realistic figure )

Languages Spoken / Written / Understood (1-poor 5-Fluent)

Spoken Written Understood
ENGLISH 3 3 3

DRUG & ALCOHOL POLICY

ALL Our Clients have very strict NO DRUG and ALCOHOL POLICY, Which is required to be
complied with at all times, which means “””ZERO TOLERENCE on ALCOHOL & DRUG”””
Your body must NOT have any ALCOHOL or DRUG substances from the time you board your flight
or commence your travel to join vessel, and Must remain so Until you have completed full contract
and returned to your home Airport / Town
If during the said period you are found under the influence of DRUG or ALCOHOL then ALL
EXPENCES incurred which will include all your travel and recruiting costs, And your relief’s
Travel and recruiting costs, And Any other costs whatsoever incurred due to your NON-
COMPLIANCE will be deducted from your salary, Which will include but not limited to “damage to
vessel her equipments and machineries, loss of charter, and any other costs Directly or indirectly
connected with your NON-COMPLIANCE
Sign & CONFIRM ACCEPTANCE OF ABOVE POLICY…

WALTER EDEWAN

FOLLOWING DOCUMENTS COPIES MUST BE SENT TO US- send to us In separate Email

ALL CERTIFICATES LISTED ON FORM TO BE SENT INCLUDING SEAMAN BOOK MAIN PAGE +
UPTO LAST 10 YEARS SEASERVICE PAGES + PASSPORT MAIN PAGE
+ USA VISAS + BRAZIL VISA + MEXICAN VISA if you have

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