20 Maxwell Road

#09-17, Maxwell House

Singapore 069113
Tel: +65 9022 6665
Fax: +65 6399 3699
Email: Operations@agapems.com.sg
MARINE SERVICES Co.Reg.No 53185703D
Application Forms

Notes: Please read the following instructions carefully.

This form is to be completed with attached and return to the Human Resource Department.

*Copies of your educational certificates and testimonials are to be submitted with the application.

Rank Applied for Expected Salary Date of application

USD 80 - USD 120/day (Depend on project
Medic 22 April 2011
location)

Applicant’s Particulars
Name as in Passport:Dede Harisurohman Nationality: Indonesia Marital Status: Single

Place of Birth:Kuningan Date of Birth:12 July 1983 Religion: Muslim

Passport No. S 653481

Issued Date:31 December 2008 Expiry Date:31 December 2013

Home Address: Desa Pangkalan No.116 Rt.15, Rw.005 Kecamatan Ciawigebang 45591, Kuningan – Jawa Barat

Education
Name of School Country From To Course Taken
Nursing Academy Berkala WIdya Husada Indonesia 2005 2005 Medical Nursing
KORPRI Senior High School Indonesia 1999 2002
Government 1 Junior High School Indonesia 1996 1999
Elementary Pangkalan 1 School Indonesia 1991 1996

Contact Person in times of Emergency

Name of Contact Person Relationship Contact Number
Haji Kusmadi Father +62852 2412 0844
Bidan Kurniasih Aunty +62857 8108 6265
Dadang Udaya Uncle +62812 9313 697

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20 Maxwell Road
#09-17, Maxwell House
Singapore 069113
Tel: +65 9022 6665
Fax: +65 6399 3699
Email: Operations@agapems.com.sg
MARINE SERVICES Co.Reg.No 53185703D

Seaman Details
Issued Authority: Ministry of
Name as in Seaman Book:Dede Country & Place of Issued: Indonesia, Tanjung
Transportation Directorate General of Sea
Harisurohman Priok
Transportation

Seaman Book No. X 007723 Issued Date:31 December 2009 Expiry Date:31 December 2012

Email Address:dede.medic@gmail.com
Home Telephone No.+62218762713 Mobile No.+6281383581562
surohman_juli83@yahoo.com

Courses Attended Certificate No Date Issued Date Expiry

Basic Safety Training 6201597094010711 18 March 2011 N/A
BOSIET IP/BOSIET/17418/2010 27 April 2010 27 April 2013
Basic Trauma Cardiac Life Support (BTCLS) No.AGD.BT-CLS 001172 12 May 2009 16 May 2012
HIPERKES / Industrial Paramedic Training 9.994/PM-I/09 27 April 2009 N/A
Basic Sea Survival SS.15292/IKS/09 2 May 2009 2 May 2012
ACLS In house training None certificate N/A N/A
BTCLS In house training None certificate N/A N/A
First Aid Training Level III 1017154 21April 2007 N/A

Sea Experience
Name of Company Type of Vessel Position From To
SMIT Singapore Crane Barge MV.IBIS Barge Medic 30 June 2010 6 January 2011
Chevron Indonesia Rig Apexindo 4 Rig Medic May 2010 2 June 2010
Transocean Drilling Company Drillship GSF Explorer Rig Medic March 2010 April 2010
Premium Drilling – Aban Offshore Singapore Rig Jack Up DD1, DD4 Rig Safety Medic June 2009 15 April 2010
Pioneer Offshore Singapore Crane Barge POE CB3 Barge Medic August 2007 December 2007
International SOS Coal, gold mining Rotating Paramedic 27 March 2006 30 June 2007

I certify that all information provided in this application is to my knowledge true and correct and that I have not willfully suppressed any material
fact.

Dede Harisurohman 22,April2011

Signature Date

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