PT. MULTIKREASI SENALAUT SERVICES
ANAKIDA BUILDING 4th FLOOR. JL.PROF DR SOEPOMO #2 JAKARTA 12810 – INDONESIA
PHONE : 021 – 8290308, FAX : 021 – 8301723, E-mail : info@multimanning.com

POSITION APPLIED FOR       
ALTERNATIVE POSITION
DATE AVAILABLE

PERSONAL DATA
LAST NAME FIRST NAME MIDDLE NAME
DATE OF BIRTH PLACE OF BIRTH
PERMANENT ADDRESS
PHONE/MOBILE NUMBERS EMAIL ADDRESS
MARITAL STATUS WIFE
PERSON TO BE CONTACTED IN CASE OF EMERGENCY RELATIONSHIP
ADDRESS & PHONE NO.

EDUCATIONAL ATTAINMENT
HIGHEST EDUCATIONAL ATTAINMENT/DEGREE
SCHOOL ATTENDED
YEAR ATTENDED

INDONESIAN LICENSES/SEAMAN’S BOOKS/CERTIFICATES AND ENDORSEMENTS
  GRADE NUMBER DATE OF ISSUANCE VALIDITY
LICENSE OF COMPETENCY
LICENSE OF ENDORSMENT
INDONESIAN SEAMAN’S BOOK
PASSPORT

BASIC/ADVANCED SAFETY COURSES
COURSE CERTIFICATE NUMBER PLACE OF ISSUANCE DATE OF ISSUANCE EXPIRY
BASIC SAFETY TRAINING
SURVIVAL CRAFT AND RESCUE BOATS
ADVANCED FIRE FIGHTING
MEDICAL FIRST AID
MEDICAL CARE
ARPA SIMULATOR
RADAR SIMULATOR
SHIIP SECURITY OFFICER
ISM CODE
PROFIENCY GMDSS
BRIDGE RESEARCH MANAGEMENT
GENERAL OPERATOR CERTIFICATE

FOREIGN LICENSES/SEAMAN’S BOOKS/CERTIFICATE OF COMPETENCY/VISA AS/VACCINATIONS
COUNTRY DOCUMENT NUMBER EXPIRY VACCINATIONS DATE OF ISSUANCE EXPIRY
YELLOW FEVER
TYPHOID / TYPHIM
DIPTHERI / TETHANUS
HEPATITIS A
HEPATITIS B

UNIFORM ISSUANCE
HEIGHT WEIGHT PANT SIZE SHOE SIZE COVERALL

MARITAL STATUS AND DEPENDENT DETAILS
NAME OF DEPENDENT DATE OF BIRTH RELATIONSHIP

HOME ALLOTMENT DETAILS
ALLOTEE RELATIONSHIP BANK AMOUNT ACCOUNT NO.

SIGNATURE OF CREW :

 DATE
IMPORTANT NOTE
By signing this application form and if I am accepted for emplyoment, I fully understand that PT MSS does not guarantee the date of my assignment
 
 
Position :
Name : DECK AND GALLEY DEPARTEMENT
SEA SERVICE (START FROM MOST RECENT)
VESSEL NAME RANK FROM
DD/MM/YY		 UNTIL
DD/MM/YY		 DURATION
MM/YY		 TYPE OF VESSEL GRT FLAG NATIONALITY OF MASTER MANNING AGENCY PRINCIPAL

COURSE ATTENDED
COURSE TITLE  
 
 
 
 
SIGNATURE OF CREW  
MSS FORM #001

Position :
Name : ENGINE DEPARTEMENT
SEA SERVICE (START FROM MOST RECENT)
VESSEL NAME RANK FROM
DD/MM/YY		 UNTIL
DD/MM/YY		 DURATION
MM/DD		 TYPE OF VESSEL GRT KILO
WATT		 ENGINE
TYPE		 FLAG NATIONALITY
OF CHIEF ENGINEER		 MANNING AGENCY PRINCIPAL REASON
FOR LEAVING

COURSE ATTENDED
COURSE TITLE  
 
 
 
 
SIGNATURE OF CREW  
MSS FORM #001/Page 2