PT Perusahaan Pelayaran EQUINOX APPLICATION FORM A. PERSONAL Name : Date of Birth & Place : Nationality : Religion : Address : Telephone number : Position applied : Email Id : KPI No. : Marital Status : Number of children : Height : Weight : Next of Kin (NOK) : Address : Size of working cloth : Telephone number : Size of Shoes : Email Id : B. PERSONAL DOCUMENT Description Number Date of issue Date Passport Seaman's Book Flag State License C. COURSES Description Date of issue Certificate No. Val Advanced Tanker Safety - Oil Advanced Tanker Safety - Chemical Advanced Tanker Safety - Gas Tanker Familiarization COW - IGS Deck Watch Keeping Engine Watch Keeping Medical First Aid Training Medical Care Advanced Fire Fighting Basic Safety Training Survival Craft Rescue Boat GMDSS - GOC ARPA simulator Radar Simulator ISM Code Training Bridge Team Management Bridge Resource Management Engine Team Management Ship Security Officer (SSO) Phot
Application FormPT Perusahaan Pelayaran EQUINOXAPPLICATION
FORMA. PERSONALName:Date of Birth &
Place:Nationality:Religion:Address:Telephone number:Position
applied:Email Id:KPI No.:Marital Status:Number of
children:Height:Weight:Next of Kin (NOK):Address:Size of working
cloth:Telephone number:Size of Shoes:Email Id:B. PERSONAL
DOCUMENTDescriptionNumberDate of issueDate of
expiryPassportSeaman's BookFlag State LicenseC.
COURSESDescriptionDate of issueCertificate No.ValidationAdvanced
Tanker Safety - OilAdvanced Tanker Safety - ChemicalAdvanced Tanker
Safety - GasTanker FamiliarizationCOW - IGSDeck Watch KeepingEngine
Watch KeepingMedical First Aid TrainingMedical CareAdvanced Fire
FightingBasic Safety TrainingSurvival Craft Rescue BoatGMDSS -
GOCARPA simulatorRadar SimulatorISM Code TrainingBridge Team
ManagementBridge Resource ManagementEngine Team ManagementShip
Security Officer (SSO)D. MARITIME LICENSETypeCertificate No.Date of
issueIssued byE. SEA SERVICE RECORDPositionVesselIMO
typeGRT/BHPFlagPeriodManagementF. MEDICAL RECORDLast Medical Check
Up:Date TakenVaccinationDate TakenMedicalMCISYellow
FeverExtensiveCholeraSimpleTyphoidTest DrugsClinicFormClinicG.
INTERVIEW RESULTPersonalityWork understandingEnglishAbility to Expr
HimselfAttitudeRecord of ExperienceTeam WorkEducation1 : Poor2 :
Below Average3 : Averange4 : Good5 : Very Good6 :
ExcellentDate,Applicant / Signature
&L&"Times New Roman,Regular"&8PT PP Equinox
Application Form&R&"Times New Roman,Regular"&8Page
&P of &NPhoto
