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Employment Application Form

Interview No: Crew I.D.:

Position applied for: Bar Server Department: Food And Beverage Date:

Surname: Yusa Dana First Names: I Komang

Br.Dinas wangsean, ds. Wisna kertaKec. Sidemen, Kab Age 22year old
Address Karangasem male
Sex:
Name Building/Block Mobile Telephone No: 08105647609
City/Town Amplapura Home Telephone No:
Zip/Post Code 80864 [email protected]
Country Indonesia E-mail address:

Date and Place of Birth: wangsean/ 27- 04 - 2001 Nationality: indonesia

Passport No: C7558689 Issue date: 10 June 2021 Issue place: Denpasar Expiry date: 10 june 2026
PERSONAL

Seaman’s Book No: G084190 Issue date: 28 may 2021 Issue place: Benoa Expiry date: 28 may 2024

Marital status: single Relationship:

Address:
Next of Kin: Telephone No:
Present Employment: Since when:
Ever applied to this
When?
Company before?
Recruitment Agency: Main departure airport:
Have you ever had any difficulties with the authorities, in any Jurisdiction or Country (i.e. Police, Customs, Immigration
etc.)? And if so, for what reasons?

This information is required to provide safety and security onboard our vessels and compliance with relevant Authorities’
requirements. Once the information provided is verified it will be destroyed and no record will be held.

Position: Name and Address of Employment: From – To (Dates): Reason for Leaving:
T HISTORY
EMPLOYMEN

Spoken Written Reading

Fair Well Excellent Fair Well Excellent Fair Well Excellent
ENGLISH ✔️ ✔️ ✔️
GERMAN
LANGUAGES

FRENCH
ITALIAN
SPANISH
RUSSIAN
OTHER:

Education Name and Place of School Years Attended Year Graduated

EDUCATION

High School SMK N 1 KLUNGKUNG 2015 2018

College MONARCH CRUISE LINE CENTER 2018 2019
Trade, Business
or Other School

SCHENGEN
MULTI / SINGLE USA Issue date: Issue place: Expiry date:
28JUL2022 Surabaya 26JUL2026
VISA

USA (C1/D1) Issue date: Issue place: Expiry date:

TYPE D PERMIT Issue date: Issue place: Expiry date:

FC7.1 Employment Application Form . . 1/2

 Employment Application Form

Duration of
Certificates for SEA-GOING ONLY No. Date of Issue Expiry Date
Training
Basic Safety Training 621201844301 26 August 2020 26 august 2025 12 days
CERTIFICATES

Section (A-VI/1.2) 6920

DIPLOMAS /

Section A-V/2 (par. 1,2,3,4,5) (state which paragraphs)

Section A-V/3 (par. 1,2,3,4,5) (state which paragraphs)
Crowd Management 621201844313 28 september 2020 28 september 2025 3 days
6920
Crisis Management 621201844317 28 september 2020 28 september 2025 3 days
6920

Are you currently under a doctor’s care with medication? YES NO ✔️

If yes, please specify:

Do you have any recurring medical problems? YES NO ✔️

If yes, please specify:
MEDICAL

Are you on any medication? YES NO ✔️

If yes, please specify:
Do you have any physical and/or mental condition that would limit your ability to perform the job you are applying for?
Height: 160 cm Weight: 55kg
State if any defect in:
Hearing:
Vision:
Speech:

We require your medical information for our legal obligation to conform with relevant laws, regulations and international
conventions which makes it obligatory for the company to hold and process such information. (International Maritime
Organization (IMO), International Labor Organization (ILO), Maritime Labor Convention (MLC), The International Convention
on Standards of Training, Certification and Watchkeeping for Seafarers (STCW). This obligation is based on the obligatory
medical examinations for issuance of the Fit-for-Duty Certificates. If your employment application is not successful, your medical
data will be immediately deleted.

I have read and understood the company’s Privacy Policy on

Collection, Processing and Protection of Personal Data

I confirm that the above is to the best of my knowledge and belief correct.
I also understand that any false statement above is reason form dismissal if engaged.

Date: Signature of applicant:

Please attach a copy of the following documents:

No Documents 1 Sea-Going 2 River √ Expiry (Comments)

1. Passport (photo, name, expiry and visa pages)1, 2 ✔️ 2026
2. Seaman’s Book 1 ✔️ 2024
3. Vaccination Book 1
4. Qualification Certificates 1, 2
5. Training Certificates 1

To be completed by the interviewer

Suggested
Name of interviewer: Date:
Positions
Languages: ENG: GER: FR: ITA: SPN: RUS: OTH:
Comments:
Evaluation Criteria:
1
Appearance: 2
INTERNAL USE ONLY

Experience: 3
Knowledge: 4
Suggested Vessels
Overall 1 2 3 4 5 1
Evaluation: Poor Fair Good Very Good Excellent 2
Interview Passed – Passed – Passed –
Failed 3
outcome: Contract offered Stand by Contract offered No offer

Signature of Interviewer:

FC7.1 Employment Application Form . . /