Proposed Form – Indonesia Cruise Service

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Position

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1. PERSONAL INFORMATION

Please fill all the columns of your personal information down below!

First Name

Last Name

NIK (National Identification Number)

Place of Birth (POB)

Date of Birth (DOB)

WhatsApp (WA) Number

Email Address

Address Line

City

Province

Zip Code

Gender

Marital Status

Height (cm)/Weight (kg)

2. PARENTS INFORMATION

Please fill all the columns of your family information down below!

Father's First Name

Father's Last Name

Mother's First Name

Mother's Last Name

3. EMERGENCY CONTACT

Please fill in the following columns related to family member or relative who can be contacted!

Emergency Contact's Full Name

Relationship

Phone Number

Emergency Contact Address Line

City

Province

Zip Code

4. PERSONAL EXPERIENCE & CERTIFICATES

Please fill in the following columns related to your experience and certificates!

Primary School

Start Year/Year of Graduation

Junior High School

Start Year/Year of Graduation

Senior High School

Start Year/Year of Graduation

College/University/Vocational School

Start Year/Year of Graduation

Passport Number

Place of Issue

Date of Issue

Expired Date

Seaman Book Number

Place of Issue

Date of Issue

Expired Date

Basic Safety Training Number

Place of Issue

Date of Issue

Safety Awareness Training Number

Place of Issue

Date of Issue

Crisis Management Number

Place of Issue

Date of Issue

Crowd Management Number

Place of Issue

Date of Issue

Proficiency in Survival Craft and Rescue Boats Number

Place of Issue

Date of Issue

Latest Land Base Experience

Position

Start Date/End Date

Second to Last Land Base Experience

Position

Start Date/End Date

Third to Last Land Base Experience

Position

Start Date/End Date

Latest Sea Service Experience

Position

Type of Vessel

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