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Section 6
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Attachment 6.1
PT SUMATRA WAHANA PERKASA
(SEA STAFF APPLICATION FORM)

Photograph
PERSONAL PROFILE
PositionApplied 3rd Engineer VesselType
Name WAHYU KURNIAWAN Date ofBirth MAROS 23 MAY 1993
Availability Date 02 NOV 2019 NearestAirport (UPG) HASANUDDIN
Address Jl Pramuka Belopa utara Age 26
Kec.Lamunre tengah Kab.Luwu
Sul Sel
Religion Moeslem Weight (kg) 54
Marital status Unmerried/ single Height (cm) 164
Nationality INDONESIA Email Address Wahyu5012147@gmail.com
Home Tel +6281258158784 HP No +6282351501208
Coverallsize L Shoesize 41
TRAVEL DOCUMENT INFORMATION
Passport No C 5082941 Date of Expiry 08.10.2024
Seaman Book No E 123389 Date of Expiry 21.01.2022
Any WorkPermit / Visa Date ofExpiry
No.

Name WAHYU KURNIAWAN Relationship Single

Jln.Pramuka Desa.lamunre tengah Kec.
ResidentialAddress Belopa Utara Kab.Luwu sulawesi Email Address Wahyu5012@gmail.com
selatan
HomeTelephone 082351501208 Contact No. 082351501208
Family Particulars (PleaseincludeParents, Spouse, SiblingsandChildren)
Name Relationship Age Occupation Employer
ILHAM WAHID Father 52 TNI AD LUWU
KARTINI NAWI Mother 50 IRT SOPPENG
- Spouse - - -
- Children (M/F) - - -
PUTRA RAHMAD Younger Brother 19 SCHOOL KARIANGO
TRI REZKY
Younger Brother 16
Seven Offshore SCHOOL MAROS
HAMDANYANI
16th – 18th Floor, Perwata
IKHA PURNAMA YoungerSister 6 Kav. 1, Pluit
Tower, Jl. Pluit Selatan Raya, SCHOOL BELOPA
- Jakarta 14440, Indonesia, Phone:
(62-21) 3002 7555, 3002 7599, Fax: (62-21) 3002 7500
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NEXT OF KIN (EmergencyContact person)

EDUCATION & PRE-SEA TRAINING DETAILS
From To Schools/Institutions/Universitiesattended QualificationsObtained

1998 2005 SD NEGERI 18 INPRES KARIANGO -

2005 2008 SMP NEGERI 1 MANDAI -
2008 2010 SMK NEGERI 1 BELOPA -
2012 2017 AMI AIPI MAKASSAR -

CERTIFICATE OF COMPETENCY
6211426096S30419 Date ofIssue 06.09.2019
CompetencyCertificate / No.
Date ofExpiry N/A
Certificatelimitation / Type COC III/2 IssuingAuthority JAKARTA
MANAGEMENT
6211426096SC30419 Date ofIssue 06.09.2019
EndorsementCertificate / No.
Date ofExpiry 06.09.2024
GOC / GMDSS Date ofExpiry
INDONESIA Date ofExpiry
FlagstateLicense
CertificateofEndorsement Issuing
Authority
Date ofExpiry
FlagstateLicense
CertificateofRecognition Issuing
Authority
DangerousCargoEndorsement Date ofExpiry
Oil/Gas/Chemical
Limitation
TRAINING CERTIFICATES
Certificates Number Date ofIssue Date
ofExpiry
Basic SafetyCourse 6211426069010118 JAKARTA 03.09.2023
Adv. Firefighting 6211426069060118 JAKARTA 23.11.2023
Advance firstaid
MedicalEmergency – First aid 6211426069070118 JAKARTA 22.04.2022
Personal safetyandsocialresponsibility
Proficiency in Survivalcraftandrescueboat 6211426069040417 MAKASSAR 21.07.2022

MedicalCare 6211426069080415 MAKASSAR 06.03.2021

Engine Team andResourchManagement(ERM) 6211426069270419 MAKASSAR 21.10.2024
Radar Observer

Seven Offshore
16th – 18th Floor, Perwata Tower, Jl. Pluit Selatan Raya, Kav. 1, Pluit - Jakarta 14440, Indonesia, Phone:
(62-21) 3002 7555, 3002 7599, Fax: (62-21) 3002 7500
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Radar Simulator
Security Awareness Training Certificate(SAT) 6211426096310415 MAKASSAR 01.02.2021
GMDSS (GOC) Course
SeaferWithDesignatedSecurityDuties(SDSD) 6211426096320415 MAKASSAR 19.01.2021
IMDG course
ShipSecurityOfficer 6211426069240415 MAKASSAR 24.01.2021
Basic TrainingAnd Oil Tanker CargoOpration(BOCT) 6211426096410117 JAKARTA 23.09.2015
Advanced Oil Tanker course 6211426069410117 JAKARTA 13.12.2022
Oil Tanker Familiarization
Oil Tanker SafetyCourse
ISM/ISPS familiarization
OFFSHORE CERTIFICATES
Certificates Number Date Date
ofIssue ofExpiry
HUET
Personal SurvivalTechnique
BOSEIT (OPITO Approved)
Pleasetickif YES
Food Handling
Crane Operator TrainingCertificate
RiggingandSlinging
MEDICAL CERTIFICATES
ULTRA MEDICAL Yes, No, NA :
Lastmedicalexamination : - CENTER IssuingFrom :
Date ofIssue JAKARTA Date ofExpiry 12 DECEMBER 2020
Remarksonhealthcondition FIT TO BE
DUTY ON
BOARD
Vaccinations
YellowFever * Date ofIssue MAKASSAR Date ofExpiry 16.03.2025
Cholera * Date ofIssue JAKARTA Date ofExpiry 12 DECEMBER
2020
Others * Date ofIssue JAKARTA Date ofExpiry 12 DECEMBER
2020

Seven Offshore
16th – 18th Floor, Perwata Tower, Jl. Pluit Selatan Raya, Kav. 1, Pluit - Jakarta 14440, Indonesia, Phone:
(62-21) 3002 7555, 3002 7599, Fax: (62-21) 3002 7500
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RECORD OF SEA SERVICES

21.01.202221.01.2022

Sea
NO
Time
GT/ KW/BH Trading Sign On Sign Off
Ship's Name Type Rank Company Year/
NT P Area Date Date
Mount
h
PT.ASL
ASL PSV
1 3921 4X2145 CADET SHIPYARD Singapore 12.01.2016 17.01.2017 1 year
SHIMPONY DP2
INDONESIA

3rd PT.ASL
PSV 3
2 ASL SINERGY 3921 4X2145 ENGINE SHIPYARD Singapore 28.03.2018 30.06.2018
DP2 mounth
ER INDONESIA

3rd PT.ASL
3
3 ASL LEO AHTS 1714 2X3003 ENGINE SHIPYARD Singapore 28.07.2018 07.11.2018
Mounth
ER INDONESIA

3rd EASTERN
ENA AHTS 6
4 3325 2X4500 ENGINE NAVIGATIO Singapore 02.01.2019 10.07.2019
ENDEAVOUR DP2 mounth
ER N Pte Ltd

Total Sea Service ofPositionAppliedfor

Type: AHT/Tug/Barge/Utilityboat/Others Years: Months:

Tanker Years: Months:

DP Certification (Pleasetickaccordingly)
TypeofCertificate Basic Advance
Limited Full
Lengthof DP Watchkeeping (total DP hours&monthsonboard)
VesselClass
DECLARATION OF APPLICANT
AnswerYes orNotothefollowingquestions. If Yes, givedetailsbelow Yes No
1 Has anypreviousemployerdismissedyouformisconduct? NO
2 Haveyou had anyseriousillness, injuryoroperationaffectionyourwork NO
3 Do you have any physicalhandicapincludingeyesightorhearing NO
4 Have you ever being convicted in a courtoflaw in any country NO
5 Can you swim YES
REFERENCES
Name Name
Company Company
Position Position

Seven Offshore
16th – 18th Floor, Perwata Tower, Jl. Pluit Selatan Raya, Kav. 1, Pluit - Jakarta 14440, Indonesia, Phone:
(62-21) 3002 7555, 3002 7599, Fax: (62-21) 3002 7500
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Contact Contact
I herebycertifythattheaboveinformationprovidedbymeistrue, completeandtomybestknowledge. I
furtherundertakethatanywillfulactonmypartwithholdinginformationor making anyfalsestatement in
theapplicationisitselfsufficientgroundsfordismissalfromthecompany.

__________________________
WAHYU KURNIAWAN
Applicant’sSignature Date
For Office use

:Received By:

____________________________
_________________
Remarks: Date

Seven Offshore
16th – 18th Floor, Perwata Tower, Jl. Pluit Selatan Raya, Kav. 1, Pluit - Jakarta 14440, Indonesia, Phone:
(62-21) 3002 7555, 3002 7599, Fax: (62-21) 3002 7500