SEAFARER APPLICATION FORM

1. CREW DETAILS: (IN BLOCK Letters)

FULL NAME RONALD ADVENTUS SITUMORANG
RANK ENGINEER
DATE OF BIRTH 23/12/1979
PLACE OF BIRTH JAKARTA
NATIONALITY INDONESIA
MARITAL STATUS MARRIED
RELIGION CHRISTIAN
MOBILE & EMAIL & SKYPE ID (+62)82135298900 [email protected] Ronald Adventus
CONTACT ADDRESS THE GREEN HILL, CLUSTER CHEDI, C3/58, CIBINONG, JAWA BARAT, INDONESIA 16913
BLOOD GROUP B+ HOME Tel.No (+62)21-83733575
PORT OF DEP & ARRIVAL JAKARTA-CGK
COVERALL SIZE XL
SAFETY SHOE SIZE 42
2. COC / COE DETAILS: (if not applicable - mention N/A)
No. Document Type Number Place / Date of Issue Expiry
1 COC III/2 6200426603-T10220 JAKARTA / 11-12-20 NA
2 COE III/2-UNLIMITED 6200426603-TA0220 JAKRTA / 11-12-20 11/12/2025
3. TRAVEL DOCUMENT: (if not applicable - mention N/A)
No. Document Type Number Place / Date of Issue Expiry
1 PASSPORT C-2418617 JAKARTA / 04-02-19 04/02/2024
2 SEAMAN BOOK / CDC H-066508 JAKARTA / 05-09-22 04/09/2027
3 ILO / MLC MEDICAL 72112 JAKARTA / 02-08-22 02/08/2024
4. STCW CERTIFICATE : (if not applicable - mention N/A)
No. Certificate Title Cert. No Place / Date of Issue
1 BST (Basic Safety Training) 6200426603-010721 JAKARTA / 15-05-21
2 PSCRB (Proficiency in Survival Craft and Rescue Boat) 6200426603-040121 JAKARTA / 26-04-21
3 FRB/FRC (Fast Rescue Boat/Craft) 6200426603-050320 JAKARTA / 17-02-21
4 AFF (Advance Fire Fighting) 6200426603-060119 JAKARTA / 14-06-19
5 MFA (Medical First Aid) 6200426603-074621 JAKARTA / 22-04-21
6 MCOB (Medical Care on Board Ship) 6200426603-080119 JAKARTA / 14-06-19
7 IMDG (International Maritime Dangerous Goods code) 6200426603-290217 JAKARTA / 18/10/17
8 CM (Crowd Management) 6200426603-130120 JAKARTA / 02-03-20
9 CMHB (Crisis Management and Human Behaviour) 6200426603-170120 JAKARTA / 02-03-20
10 SSO (Ship Security Officer) 6200426603-240219 JAKARTA / 05-09-19
11 ERM (Engine Room Resource Management) 6200426603-270219 JAKARTA / 05-09-19
12 DP Maintenance (DPm) S17/200/2022_LERUS SINGAPORE / 05-07-22

5. OTHER TRAININGS & CERTIFICATION: (if not applicable – mention N/A)

No. Document Type Number Place / Date of Issue Expiry
1 H2S – Basic 2110126139-6312 JAKARTA / 10-12-20 10 Dec 2023
2 H2S – OPITO 52519014080822-467076 DUBAI / 08-08-2022 7 Aug 2024
3 HUET – OPITO 52515095100822-467232 DUBAI / 10-08-2022 10 Aug 2026
4 Safe Welding – OPITO 467400 DUBAI / 11-08-2022 10 Aug 2025
5 MARLINS Test : 92% A9D8DA83A607E285 SSR / 14-10-21 NA
6. NEXT OF KIN DETAILS: (Mandatory)
Contact Details
No. Name Relationship with Crew Address
(E-mail / Telephone
1 ANNISA FARMASURI WIFE SAME ADDRESS (62)8119403893
2 ROWIENA C. JUDITH DAUGHTER SAME ADDRESS NA

DATE: 28 Feb 2023

PLACE: JAKARTA
CREW NAME & SIGN: RONALD ADVENTUS SITUMORANG

03F-002-2
 COMPLETE SEA – SERVICE DETAILS
( Last 5 years from last to recent)

Name: RONALD ADVENTUS Rank: CE Register Code: 6200426603

Vessel
Company Name Rank Flag Vessel Name Signed On Signed Off Propulsion G.R.T Engine Type BHP / KW
Type
P&O Marine Logistic CE Marshall Island T-Beleuzi 04-09-22 20-01-23 CPP PSV DP-2 3261 Niigata 8L28HDX 7450 / 5428
SM Asia Pte Ltd CE St Vincent GR S. Bateleur 20-07-22 23-08-22 FPP PSV DP-2 3601 Cummins QSK-60 13662 / 10180
SM Asia Pte Ltd CE Panama S. Bravo 25-02-22 29-06-22 FPP OSV DP-1 1627 CAT 3516B 6200 / 4623
JMS CE Bahrain Jana-14 16-09-21 18-12-21 FPP CTV 272 CAT-32 ACERT 4600 / 3430
CTEP-MEO CE Thailand Uniwise Advantage 22-02-21 28-08-21 CPP OSV DP-2 2274 Niigata 8L28HDX 7450 / 5428
CTEP-MEO CE Panama Miclyn Energy 20-04-20 28-09-20 CPP OSV DP-1 2031 CAT 3516B 5149 / 3840
CTEP-MEO CE Thailand Uniwise Advantage 23-06-19 27-10-19 CPP OSV DP-2 2274 Niigata 8L28HDX 7450 / 5428
CTEP-MEO CE Panama Miclyn Energy 24-12-18 27-04-19 CPP OSV DP-1 2031 CAT 3516B 5149 / 3840
CTEP-MEO CE Thailand Uniwise Adventure 26-07-18 18-11-18 CPP OSV DP-2 2274 Niigata 8L28HDX 7450 / 5428
CTEP-MEO CE Thailand Uniwise Advantage 25-01-18 28-05-18 CPP OSV DP-2 2274 Niigata 8L28HDX 7450 / 5428
CTEP-MEO CE Panama Miclyn Energy 23-08-17 28-12-17 CPP OSV DP-1 2031 CAT 3516B 5149 / 3840
CTEP-MEO CE Panama Miclyn Enterprise 24-03-17 27-07-17 CPP OSV DP-2 2297 CAT 3516B 5149 / 3840
CTEP-MEO CE Panama Miclyn Energy 23-10-16 25-02-17 CPP OSV DP-1 2031 CAT 3516B 5149/ 3840
CTEP-MEO CE Panama Miclyn Enterprise 21-05-16 28-09-16 CPP OSV DP-2 2297 CAT 3516B 5149 / 3840
CTEP-MEO CE Panama Miclyn Energy 06-12-15 06-03-19 CPP OSV DP-1 2031 CAT 3516B 5149 / 3840
CTEP-MEO CE Panama Miclyn Enterprise 01-09-15 15-11-15 CPP OSV DP-2 2297 CAT 3516B 5149 / 3840
CTEP-MEO CE Panama Miclyn Energy 05-03-15 01-06-15 CPP OSV DP-1 2031 CAT 3516B 5149 / 3840

I hereby certify that the information given on this form is truthful, complete and correct to the best of my knowledge.

I understand that any false statements or concealment of fact will be grounds for dismissal. 28-02-2023
DATE SIGNATURE