APPLICATION FORM

( CURRICULUM VITAE )

Full Name AGUS ZALI

Place & Date Of Birth MOJOKERTO, 5 APRIL 1967
Gender MALE
Religion MOESLEM
Permanent Address JL. CICADAS NO. A7 RT/RW KECAMATAN KEPANJEN KIDUL
KELURAHAN BENDO KOTA BLITAR KODE POS 66116
Nationality INDONESIAN
Mobile Phone +6282142005777
Email Addres Aguszali55@yahoo.com

CERTIFICATE OF COMPETENCY
No. Detail Number Place Issued Date Issued
1. ENGGINER OFFICER CLASS IV 6200098230T40303 JAKARTA,09 JANUARY 2003 UNLIMITED
2. ENGINEER OFFICER CLASS III 6200098230S30116 JAKARTA,07 OCTOBER 2016 UNLIMITED
3. ENDORSEMENT III 6200098230SC0116 JAKARTA,11 June 2014 31 December 2016
FURTHER DETAIL
No. Detail Number Place Issued Date Issued Expire
1. PASPORT T 064872726 BLITAR 12 OCT 2016 12 OCT 2021
2. SEAMAN BOOK E 143932 SURABAYA 16 JANUARY 2017 16 JANUARY 2020

CERTIFICATE OF PROFIENCY
No. Name of Certificate Number Place Issued
1. BASIC SAFETY TRANING 6200098230010309 26 August 2015
2. PROFICIENCY 6200098230040309 26 August 2015
3. ADVANCED FRE FIGHTING 6200098230060309 26 August 2015
4. MEDICAL FIRST AID 6200098230080308 26 August 2015
5. MEDICAL CARE AN BOARD SHIP 6200098230080309 26 August 2015
6. BOCT 6200098230390518 10 January 2018
7. ENDORSEMENT ATTESTING(MPA) 6200098230S30116 10 October 2016
8. ATT III MANAJEMEN 6200098230S30116 07 October 2016
9. SHIP SECURITY OFFICER 6200098230240315 11 September 2015
10. SEAFERERS WITH DESIGNATED SECURITY DUTIES 6200098230320315 14 September 2015
11. SECURITY AWARENESS TRAINING 6200098230310315 14 September 2015
12. ENGINE ROOM RESOURCE MANAGEMENT 6200098230270115 26 Oktober 2015

PERSONAL HISTORY
No. VESSEL NAME/FLAG VESSEL TYPE/TRADE AREA GRT/BHP RANK SIGN ON SIGN OFF
1. MT. KENCANA 7 MT/API 759/2029 MASINIS - II 06-05-2014 12-11-2014
2. TB.CANTIKA 1 TUG BOAT/API/NVC 282/2000 CH/ENGINEER 22-11-2014 04-08-2016
3. KM.MAJU 68 CARGO 1766/735 CH/ENGINEER 06-10-2016 01-01-2017
4. KM.PHILIPS CARGO 658/800 CH/ENGINEER 17-02-2017 10-06-2017
5. SPOB. SEROJA VII OIL TANKER 2384/1300 CH/ENGINEER 09-04-2018 11-12-2018
*For further information of certificate’s availability, could be checked at official homepage //http: www.pelaut.dephub.go.id
Sincerely yours,

AGUS ZALI