Pass Fail

Recruitment
Initials
Ops. Dept. Intro to Principal

PERSONAL DATA/APPLICATION FORM

S
BSM Crew Service Centre Philippines, Inc.
Rank/Position Applied For: 4th
_____________________________
Engineer

Last Name: First Name Middle Name

Pandiangan Martua Franciskus

Home Address: Tel. No.

Kav.Sagulung Mandiri Blok E No.107,Batam
Passport Photo
Contact Address: Cell No. +62822 4633 9600
Papanggo Street II C No.62,;Tj.Priok,North Jakarta,
Email add: [email protected]
Place of Birth: Civil Status: Single
Batang Toru
Wedding Date:
Course Finished: Year Attended Name of School:
2013 From:(dd/mm/yy) To: (dd/mm/yy) Maritime Academy Yogyakarta

10/09/09 30/10/13
Interests/Activities/Hobbies:
Badminton

Languages Spoken (pls. check all applicable For Office Staff Use Only:
choices):  IHTS Height: _______
162 Cm

✔ English Blood Pressure:_____________
120/70 Weight: _______
54 Kg
 Filipino
Religion: ___________________
Catholic BMI: _______
Normal
 Others_________________________
SSS No.: TIN No.: PAG-IBIG No.: PHILHEALTH No.:

Cholera Exp.: Yellow Fever Reference No.: Year Started Seagoing Years in Present Employment:
Employment:
L00-0909557
2012 02/06/2020
Next of Kin
Name: Date of Birth (dd/mm/yyyy): Relationship:
Mei Regina Pandiangan 05/05/19o87 Blood Sister
Address: Telephone No.:
Kav.Sagulung Mandiri Blok E No.107,Batam +62821 6903 0835
Children Below 21 Years Old
Name Sex Date of Birth (dd/mm/yy)

Total No. of Children:

Parents Details
Mother’s Maiden Name: Tumaide Br Lumbanbatu Father’s Name: Robbet Donatus Pandiangan
Date of Birth: 31/12/1958 Date of Birth: 04/12/1950
Home Address: Kav.Sagulung Mandiri Blok E No.107,Batam

BSM/Ser 11/Effective 19.06.18/PDAF

 SEA-GOING EXPERIENCE
(most recent vessel first)

Previous Salary: 1200

Salary Expectation: 1700

Foreign Principal & Signed on Signed off No. of Type of DWT & Nat. of Nat. of
Local Agency Rank Vessel's Name & Flag Trade Route M.E. Make BHP or KW Cause of Discharge
Address (dd/mm/yy) (dd/mm/yy) Months Vessel GRT Master/Offs Ratings

Jl.Boulevard Multi Jaya Engine MT.TRUST HONOR & Near Product-Ch 7088 & 4565 Yanmar 2438 or 1818 Finish Contract Indonesia Indonesia
Bar.Raya Blok B2 Samudera,PT Cadtet Indonesia Coastal 01/05/2012 20/12/2012 7M 20D emical
No.28,North Voayage Tanker
Jakarta City,Special
Capital
The Region Of
Prominence Indobaruna Bulk Engine MV.CERDAS & Indonesia Near Bulk 10423 & MAN B&W 5227 or Finish Contract Indonesia Indonesia
Jakarta,14240
Office Tower Lantai Transport,PT Cadet Coastal 15/03/2013 15/12/2013 9M 3D Carrier 6199 3900
19 Jl.Jalur Sutera Voyage Handy Size
Barat Kav.15 Alam
Sutera,Tangerang,1
The Prominence Indobaruna Bulk 4th MV.HEBAT & Indonesia Near Bulk 4472 & 2654 Daihatsu 3753 or 2799 Finish Contract Indonesia Indonesia
5143-Indonesia
Office Tower Lantai Transport,PT Engineer Coastal 23/06/2016 05/04/20181Y 9M 14DCarrier
19 Jl.Jalur Suteta Voyage Handy Size
Barat Kav.15 Alam
Sutera,Tangerabf,15
The Prominence Indobaruna Bulk 4th MV.OCEANIC International Bulk 10633 & Daihatsu 5229 or 3900 Finish Contract Indonesia Indonesia
143-Indonesia
Office Tower Lantai Transport,PT Engineer PROGRESS & Indonesia 01/07/2018 30/07/2019 1Y 1M Carrier 6943
19 Jl.Jalur Alam Handy Size
Suteta Barat
Kav.15 Alam
Jl.Pelabugan Bahtera Maju 3rd MT.BAHTERA KAPUAS Near Product 4626 & 2564 Mitsubishi 2011 or Finish Contract Indonesia Indonesia
Sutera,Tangerang,1
Kavling 1 Selaras,PT Engineer & Indonesia Coastal 08/11/2019 02/06/2020 6M 25D Tanker 1499
5143-Indonesia
Kabil,Kelurahan Voyage
Kabil,Kecamatan
Nongsa-Batam

BSM/Ser 08/Effective 21.01.13/PDAF 2 of 5

 CERTIFICATION AND OTHER DOCUMENTS
LICENSES AND DOCUMENTS
DATE ISSUED EXPIRY DATE LEVEL NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
CERTIFICATE OF COMPETENCY (OFFICERS) 25/06/2018 Officer Engineer III 6201592528S30218
Unlimited 6201592528S30218
Management
CERTIFICATE OF ENDORSEMENT (OFFICERS) 23/07/2018 Officer Engineer III 6201592528SC0218
23/07/20236201592528SC0218
Management
CERTIFICATE OF PROFICIENCY (NWK / EWK)
CERTIFICATE OF PROFICIENCY (ABLE SEAFARER)
BOARD LICENSE
NC I - NC III
SEAMAN'S BOOK 20/11/2020 15/05/2023 F141125
PASSPORT 15/05/2018 25/05/2023 C0253880
U.S. VISA
POEA E-Registration (ERN)
GOC
NATIONAL CERTIFICATIONS
DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
BASIC SAFETY COURSE
COP BT 07/09/2020 07/09/2025 6201592528010320
ADVANCE SAFETY COURSE
CoP Advanced Training in Fire Fighting 07/09/2020 07/09/2025 6201592528060320
CoP Proficiency in Survival Craft & Rescue Boat 07/09/2020 07/09/2025 6201592528040320
CoP Medical Emergency - First Aid 22/01/2016 Unlimited 6201592528070316
CoP Medical Care 30/09/2015 Unlimited 6201592528082515
CoP Proficiency in Fast Rescue Boat
TANKER TRAINING CERTIFICATES
CoP Basic Training Oil/Chemical Tanker 07/09/2020 07/09/2025 6201592528390320
CoP Basic Training Liquefied Gas Tanker 05/10/2020 05/10/2025 6201592528370320
CoP Advanced Training in Oil Tanker 17/09/2020 17/09/2025 6201592528410320
CoP Advanced Training in Chemical Tanker
CoP Advanced Training in Liquified Gas Tanker
NAVIGATIONAL
CoP Ship Security Officer 29/02/2016 Unlimited 6201592528240116
CoP SDSD / SAT 30/11/2015 Unlimited 6201592528310315
Safety Officer Course
ECDIS (Generic)
ECDIS (Specific)
BSM/Ser 09/Effective 19.06.18/PDAF 3 of 5
 CERTIFICATION AND OTHER DOCUMENTS
FLAG DOCUMENTS & CERTIFICATES
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
BSM/Ser 08/Effective 27.05.19/PDAF 4 of 5
 S
BSM Crew Service Centre Philippines, Inc.
WORKING EXPERIENCE (pls. check all applicable)

✔ WATER TUBE BOILERS  HEAVY LIFT OPERATORS
 DUAL EVAPORATION BOILERS  COMPUTERS
✔
 THERMAL OIL BOILERS  HYDRAULIC POWER PACKS
 MEDIUM SPEED ENGINES  SATELLITE TELEX
 SLOW SPEED ENGINES  RADIOTELEX
 ELECTRIC WELDING  ETHYLENE OPERATIONS
 GAS WELDING  DECK CRANES
 ELECTRONICS  OBO OPERATION
 AUTOMATION  INERT GAS SYSTEMS
 FRAMO PUMPS  REEFER CONTAINERS
 SUBMERSIBLE PUMPS  DERRICKS
 CRUDE OIL WASHING  TURBO GENERATORS
 BOW THRUSTER

Shore Employment Details

DATE
FROM TO Nature Of Employment Employers Name and Address

Working Gear Size

Collar (Cm): 14-14 1/2 Chest (Cm): 41 Waist (Cm): 73-78

Shoes (Cm): 25,5 Winter Jacket: S

Rain Coat: S

DECLARATION
I certify that the above information is true and accurate. No Certificate of Competence or License issued to me
has ever been revoked or suspended. Any false information would lead to denial of application.
I agree that during this application process I will be subjected to a computer based Professional and English
Language assessment test. The results of which is form part of this application.

I hereby confirm that I had no jail term and not admitted to a mental institution prior employment via BSM Crew
Service Centre Philippines, Inc.
I hereby confirm that I was never repatriated on medical grounds nor ever involved in an accident on board nor
ever required medical treatment following contract completion.
I hereby confirm that I had no past history of any serious medical condition which will affect my work ability at
sea.
I hereby confirm that I had not taken any disability compensation from any employer in the past due to a
condition which permanently affect my ability to work at sea.

MARTUA FRANCISKUS PANDIANGAN 03 December 2020

Signature Date

BSM/Ser 12/Effective 19.06.18/PDAF 5 of 5