APPLICATION FORM

Full Name : PURWANTO

Nationality : Indonesia
Place and Birth : Medan, 24 Januari 1967
Sex : Male
Status : Meried
Religion : Moslem
Permanent Address : Jl. Beringin Gg. Puyuh No. 17 Psr. VII Tembung

NATIONALITY SERTIFICATE
No Description Number Issued At Date of Issued Date of Expire
1 Passport A 6942311 Belawan 02 Desember 2013 02 Desember 2018
2 Seaman's Book C 003975 Belawan 27 November 2013 26 November 2016

SERTIFICATE
No Type Number Place, Date of issued Date of expire
1 AMK. A TDL. 251/II/C/0447/I/D.II-93 Jakarta, 04 Februari 1993 No. Limit
2 Engginer Class III 620002950T30101 Jakarta, 27 Agustus 2001 No. Limit
3 Endorsement 6200029507TC0101 Jakarta, 16 October 2013 14 October 2016
4 COR 000240EII Malaysia, 4 November 2009 28 Oktober 2010
5 Seaman Card 200624000892 27 Oktober 2009 26 Oktober 2010

SORT COURSE CERTIFICATE

No Certificate Number Place, date of issued
1 Basic Safety Training (BST) 6200029507010104 Jakarta, 13 Desember 2004
2 Survival Craft And Rescue Boat (SCRB) 6200029507040104 Jakarta, 13 Desember 2004
3 Advance Fire Fighting (AFF) 6200029507060104 Jakarta, 13 Desember 2004
4 Medical Fisrt Aid (MFA) 6200029507070104 Jakarta, 13 Desember 2004
5 Medical Care 6200029507080104 Jakarta, 13 Desember 2004
6 Tanker Familiarization 6200029507090104 Jakarta, 13 Desember 2004
7 Oil Tanker Specialized 6200029507100104 Jakarta, 13 Desember 2004

SEA REFERENCE
Engine Type of Period
No. Name of Vessel Flag Rank HP
Type Vessel From To
1 KM. Island VI Indonesia Cadet 4000 Akasaka Tanker 02.09.92 07.01.93
2 KM. Tapac III Indonesia 3 rd Eng 2000 Mann Cargo 19.05.93 17.11.93
3 KM. Megah I Indonesia 2 nd Eng 2300 Hansin Cargo 27.06.94 15.05.94
4 SP. Welf Indonesia 3000 Hansin Supply 29.09.94 20.05.94
5 MV. Everest Honduras 2 nd Eng 2500 Mann Cargo 27.05.95 27.09.95
6 MT. Irwin Pioner Indonesia CH Eng 2000 Hansin Tanker 21.10.95 25.05.99
7 KM. Kabanjahe Indonesia CH Eng 2100 Hansin Cargo 15.09.00 21.02.01
8 MT. Irwin Pioner Indonesia CH Eng 2000 Hansin Survey 26.03.02 24.01.04
9 SV. Maersk Hander Singapore 2 nd Eng 2322 Hansin Suplly 04.03.04 08.07.05
10 SV. Star Tide Singapore 2 nd Eng 4700 Mann Suplly 20.08.05 24.12.05
11 MV. Pluto Malaysia CH Eng 4x522 Cummins Ferry Cruis 27.07.06 27.12.06
12 MV. Topaz Malaysia CH Eng 2x1000 Detroit Supply 15.05.07 18.08.07
13 MV. IOS Jaguar Malaysia CH Eng 2x2000 Whichman Work Boat 31.05.08 21.08.08
14 MV. IOS Jaguar Malaysia CH Eng 2x2000 Whichman Work Boat 09.10.08 27.12.08
15 MV. IOS Jaguar Malaysia CH Eng 2x2000 Whichman Work Boat 15.10.09 15.01.10

Yours Faithfully

PURWANTO