BSM Crew Processing Form – CREW APPLICATION

Date of Processing (Today)

Position Approved

KTP No. / NIK

First Name

Last Name

Place of Birth

Date of Birth

Gender

Phone No/ WA

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Passport No.

Passport Place of Issues

Passport Issues Date

Passport Expired Date

Seaman Book No.

Seaman Book Expired Date

Family/ Contact Person

Some description about this section

Your Last Education (School Name)

Duration

School Address

Marital Status

Wife's Name

Married Date/ Year

Wife's Place/ Date of Birth

Name of Father

Father Place of Birth

Father Date of Birth

Name of Mother

Mother Place of Birth

Mother Date of Birth

Employment Details

Do You Have Previous US Visa

US Visa , Date/Place of issuance

Do You Have Previous Schengen Visa

Schengen Visa Issue Date

Schengen Visa Expired Date

Embarkation Information

Leave it blank if you don't know the information below:

Company Name

Port of Call

Name of Vessel/ Ship

Country

Join Date

Visa Required

If your answer other Visa or Required More Than One Visa, Please Select Country

1. Flight No.

Date

ETD

Initial Airport from - to

ETA

2. Flight No.

Date

ETD

Initial Airport from - to

ETA

3. Flight No.

Date

ETD

Initial Airport from - to

ETA

Do You Have Valid Medical Check Up?

If Yes, Medical Expired Date

Do You Have Valid Yelow Fever?

If Yes, Yellow Fever Expired Date

Have you been vaccinated against Covid-19?

Tipe of Vaccine