Reporting Form – Indonesia Cruise Service

Position

Formal Photograph Upload (Max. 5 MB)

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Date of Report

I. PERSONAL INFORMATION

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

First Name

Last Name

NIK/National Identification Number

Place of Birth

Date of Birth

Whatsapp Number

Email

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!

Full Name

Relationship

Email

Phone/Mobile

4. PERSONAL EXPERIENCES

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

College/University/Vocational School

Location

Start Year

Passport & Seaman Book

Passport No.

Place of Issued

Date of Issued

Expired Date

Seaman Book No.

Place of Issued

Date of Issued

Expired Date

STCW Certificate

Basic Safety Training No.

Place of Issued

Date of Issued

Security Awareness No.

Place of Issued

Date of Issued

Crisis Management No.

Place of Issued

Date of Issued

Crowd Management No.

Place of Issued

Date of Issued

Other Certificate

C1D Visa No.

Date of Issued

Date of Exipred

Schengen Visa No.

Date of Issued

Date of Exipred

Medical Report Date of Issued

Medical Report Date of Expired

Yellow Fever Date of Issued

Yellow Fever Date of Expired

MMR Date of Issued

Ship Cook Certificate No.

Date of Issued

Date of Exipred

File Upload

Ship Cook

Employment Records

Last Vessel Name

Position

Type of Vessel

Sign on

Sign Off

Remark