MPM 6.

13B
Rev 0/2015-08-01
Page 1 of 5

SEAFARER’S APPLICATION FORM (TANKER)

Date:
Position Applied : Bsn Cum Pump Name : Azis Hanapi
Man
Date of Birth : 02-12-1983 Place of Birth : Bilonga
Status : Married Nationality : Indonesian
Contact no : +62 81311664090
Email Address : azishanapi@yahoo.co.id
Height : 166 cm Weight : 75kg
Safety Shoes Size : 41 Coverall size :
(S/ M/ L/ XL)
Shirt Size (Officer (30”/ 32”/
: (S/ M/ L/ XL) Pants Size (Officer only) :
only) 34”/ 36”)
Address : Manongkoki Kec.Polongbangkeng Utara Kab.Takalar Sul-Sel
Name of next Kin : Sukma mi’radjiwanti Relationship : Married
Address : Manongkoki Kec.Polongbangkeng Utara Kab.Takalar Sul-Sel
Contact no : +6281243975784

Travel Documents
Subject Number Issued Date Expiry Date Issuing Authority
International Passport B7594161 10 OCT 2017 10 OCT 2022 Balikpapan
Seaman Book C000244 09 OCT 2017 15 Aug 2020 Tg.Priok
US Visa – Type D
Malaysian Seaman ID 201353002142 08/02/2018 14/02/2019 Port Kelang

Educational Background
Name of School From To Type of certificate received upon
Graduation
PGRI High School 1998 2001 Ijazah

Certificate of Competence
Type Grade Flag Certificate Number Issued Date Expiry Date
National COC ANT-D Indonesian 6200402523340717 14 Feb 2017 Limited
COC Endorsement
National GMDSS
GMDSS Endorsement
Malaysian COR

Your last wage 2000 USD

Your expected wage 1300 USD

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MPM 6.13B
Rev 0/2015-08-01
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SEAFARER’S APPLICATION FORM (TANKER)

Rank/Name:
Other Courses / Certificates
Subject Country Number Issued Expiry
Basic Training (V1/1) Jakarta 6200402523011114 Sept 4nd 14 Sept 4nd 19
-Personal Survival Techniques (VI/1-1)
-Fire Prevention & Fire Fighting (VI/1-2) Jakarta 6200402523060713 June 20nd 13 June 20nd 18
-Elementary First Aid (VI/1-3)
- Personal Safety & Social Responsibilities
(VI/1-4)
General Tanker Familiarization / Basic Training
in Oil and Chemical Tanker Cargo Operations Jakarta 6200402523390715 March 25th 15 March 25th 20
(V/1-1)
Medical First Aid (VI/4-1) Jakarta 6200402523071114 Sept 11th 14 Sept 11th 19
Medical Care (VI/4-2)
Specialized / Advanced Training in Oil Tanker
Jakarta 6200402523100713 June 14nd 13 June 14nd 18
(STOT) / (ATOT)
Specialized / Advanced Training in Chemical
Tanker (STCT) / (ATCT)
ECDIS – Generic
ECDIS - Type Specific:
___________________
Bridge Team Management Awareness Course
Engine Room Simulator Course
Ship Simulator and Bridge Teamwork
Bridge Resource Management
Engine Resource Management
Ship Security Officer
Ship Security Awareness Training Jakarta 6200402523311114 Aug 27th 14 Aug 27th 14
Designated Security Duties Jakarta 6200402523321114 Aug 27th 14 Aug 27th 14
Ship Safety Officer Course
Radar Observation and Plotting
ARPA
Risk Assessment
Incident Investigation
Auditor/Lead Auditor Training
AMOS FOR WINDOWS
Welding Certificate
Food Handling Certificate (For Cook and Msm
only)
High Voltage Certificate
Carrying Dangerous and Hazardous Cargoes
Crude Oil Washing/Inert Gas System
Operations
Welding Certificate

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MPM 6.13B
Rev 0/2015-08-01
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SEAFARER’S APPLICATION FORM (TANKER)

Basic Lathe Machine Course
Free Fall Lifeboat Familiarization
Framo Course
Shore-Based Fire Fighting
Ship Handling Simulator
Cargo Handling Simulator Training for Product
Tanker
Cargo Handling Simulator Training for Crude
Oil Tanker
Cargo Handling Simulator Training for
Chemical Tanker
ISM Awareness Course

D&A tests on:

Yellow Fever Vaccination on: 09 Feb 2017 Date of Expiry 09 Feb 2027
Pre-Medical on: 03 Aug 2018 Date of Expiry : 03 Aug 2020
Others -

Rank Name Bosun Cum Pump Man

Vessel Name Jm.Sutera 5

ID Number - Malaysian
EFP account number – Malaysian

Bank Name MANDIRI

Beneficiary Name AZIS
Bank account number 900-00-1454977-9
Swift Code / BIC* BMRIIDJA

*- If you don’t know your Swift Code / BIC please kindly check with relevant bank. This is requested for remittance
purpose.

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MPM 6.13B
Rev 0/2015-08-01
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SEAFARER’S APPLICATION FORM (TANKER)

Rank/Name:
Previous Sea Experience
Vessel Flag Employer Engine Type of Year GRT Rank Period
Name Type & Vessel Built From-
KW To
MT. Agios International Yanmar 1980 21.05.05-
Panama Oil/Tanker 3082 A/B
Nikolaos Tanker 01.04.06
MT. Agios International Yanmar 1980 Pump Man 01.04.06-
Panama Oil/Tanker 3082
Nikolaos Tanker Cum Bosun 10.05.07
MT. Agios International Yanmar 1980 Pump Man 28.02.08-
Panama Oil/Tanker 3082
Nikolaos Tanker Cum Bosun 18.03.09
DS. Sevan Bahama,Nassa Bow 2008 06.01.10-
Sevan Marine Drilling Ship 50.663 Painter
Driller u Draster LG 28.03.10
MT. FPSO B&W 1980 Deck 13.06.10-
Brazil Petrobraz FPSO/VLCC 132.715
Brazil Maintenance 28.09.10
B&W Oil 1986 19.12.10-
MT. Hercules Port Kelang SMS Sdn Bhd 143.941 Pump Man
Tanker/VLCC 10.10.11
B&W Oil 1986 12.01.12-
MT. Hercules Port Kelang SMS Sdn Bhd 143.941 Pump Man
Tanker/VLCC 26.12.12
B&W Oil 1986 26.01.13-
MT. Hercules Port Kelang SMS Sdn Bhd 143.941 Pump Man
Tanker/VLCC 05.06.13
MT. Budi Cst Belchem Yanmar 2005 Pump Man 20.08.13-
Port Kelang Oil Tanker 5107
Mesra Singapore.Pte.Ltd Cum Bsn 24.04.14
MT. Budi Cst Belchem Yanmar 2005 Pump Man 13.06.14-
Port Kelang Oil Tanker 5107
Mesra Singapore.Pte.Ltd Cum Bsn 13.02.15
MT. Atlantic PT. Waruna Nusa B&W 10.04.15-
Belawan Oil Tanker 18447 Pump Man
Point Santana 1989 04.01.17
6 D K M-36 30- 16-Feb-
Cst.belchem DAIHATSU Chemical 04- 2017/04-
Jm.Sutera 1 Port Kelang 5532 Bsn/PumpMan
singapore.Pte.Ltd 2942 Tanker 2007 Sept-
KW,600 2017
6 D K M-36 12 31 Oct-
Cst.Belchem DAIHATSU Chemical June Bsn/PumpMan 2017/28-
Jm.Sutera 3 Port Kelang 5532
Singapore Pte.Ltd 2942 Tanker 2007 Juue-
KW,600 2018
B&W 18 Bsn/PumpMan 10 Aug
MT.Chemtrans Cst Belchem
Monrovia 5s50MC Oil Tanker July 22181 2018/13
Rouen Singapore Pte.Ltd
6078 kw 2000 Apr 2019

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MPM 6.13B
Rev 0/2015-08-01
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SEAFARER’S APPLICATION FORM (TANKER)

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