CREW INFORMATION FORM

ALLIANZ-FRM-0202.14

First Name: Anggun Putra Sur Name: Utama

Rank/Post: Chief Officer Nationality: Indonesia
Permanent Address: Current Address:
Taman Yasmin, Jl. Teratai I No. 16 Taman Yasmin, Jl. Teratai I No. 16
Cilendek Barat – Bogor Barat, Cilendek Barat – Bogor Barat,
Indonesia Indonesia

Date of Birth: 09-07-1978 Age: 44 year

Height: 170 cm Weight: 78 Kg
Coverall Size: XL Shoe Size: 42
Religion: MOSLEM Next of Kin: Dya Puspita Sari
Contact No.: +62 -81212969668
Details of NOK: WIFE
E-mail: anggun_raka@yahoo.com

DATE OF EXPIRY PLACE OF

DOCUMENTS NUMBER
ISSUE DATE ISSUE

Passport 17-12-
C6993168 17-12-2020 BOGOR
2025
27-03- Tg. Priok -
Seaman Book I 028213 27-03-2023
2026 Jakarta
DATE OF DATE OF PLACE OF
COC NUMBER
ISSUE EXPIRY ISSUE
COC – CLASS 1 (MASTER) 6200005042N10215 04-10-2019 UNLIMITED JAKARTA
COE 6200005042NA0219 11-10-2019 11-10-2024 JAKARTA
[Endorsements]
[Endorsements]
[Others] Ratings As Able
Seafarer Deck
DATE OF DATE OF PLACE OF
STCW CERTIFICATES NUMBER
ISSUE EXPIRY ISSUE
C6993168 17-12-2020 17-12- BOGOR
Passport
2025
27-03- Tg. Priok -
Seaman Book I 028213 27-03-2023
2026 Jakarta
COC (STCW 2010) 6200005042N10215 04-10-2019 UNLIMITED JAKARTA
COE from vessel's Flag
6200005042NA0219 11-10-2019 11-10-2024 JAKARTA
State
Fire Prevention and Fire
Fighting
Personal Survival
Techniques

Revision 00. Original Date: 15/09/2015. Version date: N/A.

Prepared by: ALLIANZ QHSE Manager. Approved by: ALLIANZ General Manager. Validated by: ALLIANZ QHSE Manager. 1 /5
 CREW INFORMATION FORM
ALLIANZ-FRM-0202.14

Personal Safety and Social

Responsibility
Elementary First Aid
SAT or SDSD (Security
Awareness)
6200005042G1022 Unlimited STIP
GMDSS 25-05-2022
JAKARTA
6200005042GA0122 STIP
ENDORS GMDSS 25-05-2022 25-05-2027
JAKARTA
General Operator 101993/SOU/T/VIII/ JAKARTA
29-08-2022 29-08-2027
Certificate - Radio 2022
6200005042030219 BP3IP
Radar Observer 03-10-2019 03-10-2024
JAKARTA
6200005042020219 BP3IP
ARPA 03-10-2019 03-10-2024
JAKARTA
6200005042280219 BP3IP
ECDIS (if applicable) 03-10-2019 03-10-2024
JAKARTA
6200005042060123 24-01- STIP
Advanced Fire Fighting 24-01-2023
2028 JAKARTA
6200005042040123 24-01- STIP
Survival and Rescue Craft 24-01-2023
2028 JAKARTA
18280001 04-11-2018 03-11-2020 SAMSON
FRC (Fast Rescue Craft)
TIARA
6200005042080118 27-11-2018 Unlimited STIP
Medical Care
JAKARTA
Advance First Aid
6200005042240219 27-09-2019 Unlimited BP3IP
SSO
JAKARTA
Shipboard Safety Officer
Cert.
Bridge Resource 6200005042230219 26-09-2019 26-09-2024 BP3IP
Management (deck JAKARTA
officers)
Engine Resource - - - -
Management (engine
officers)
Hazardous Cargo (IMDG)
DATE OF DATE OF PLACE OF
OTHER CERTIFICATES NUMBER
ISSUE EXPIRY ISSUE
BST (Basic Safety 6200005042010123 24-01- STIP
24-01-2023
Training) 2028 JAKARTA
MFA (Medical First 6200005042070118 27-11-2018 Unlimited STIP
Aid) JAKARTA
28539014300822139 30-08-2022 29-08- LERUS-
H2S - OPITO 2024 JAKARTA
71345928140219 14-01-2023 13-01- GTSC - UAE
HUET - OPITO 24800 2027
FRC COAXWAIN 496638 20-01-2023 19-01-2026 GTSC - UAE

Revision 00. Original Date: 15/09/2015. Version date: N/A.

Prepared by: ALLIANZ QHSE Manager. Approved by: ALLIANZ General Manager. Validated by: ALLIANZ QHSE Manager. 2 /5
 CREW INFORMATION FORM
ALLIANZ-FRM-0202.14

CARRIAGE OF
496535 19-01-2023 18-01-2026
HAZARDOUS CARGO
SAFE LIFTING 496534 16-01-2023 15-01-2026
ADNOC HSE INDUCTION 496533 14-01-2023 13-01-2025

Revision 00. Original Date: 15/09/2015. Version date: N/A.

Prepared by: ALLIANZ QHSE Manager. Approved by: ALLIANZ General Manager. Validated by: ALLIANZ QHSE Manager. 3 /5
 CREW INFORMATION FORM
ALLIANZ-FRM-0202.14

Sea Service History

Vessel Type/ GRT/HP/ Type of Area of
Rank Operation
Company Sign-on Sign-off
Name Make KW Operation
AHTS 1621 / 5200 Chief TOWNING ALLIANZ MIDDLE UAE
AMIL 16 05.09.23 07.12.23
DP1 HP Officer OPERATION EAST (Mamoet)
AHTS 1621 / 5200 Chief ALLIANZ MIDDLE GHASHA FIELD –
AMIL 16
Officer SSRV EAST
13.01.23 18.07.23
DP1 HP UAE
Chief PT. SALAM JAVA SEA -
PETRO KASIM ASD TUG 343 / 4400 HP STATIC TOW 10.09.22 30.12.22
Officer BAHAGIA INDONESIA
Chief Hose Handling, Sharjah - UAE
SL AL KOUT MULTI CAT 255 / 1716 kw Officer Assist Tanker SMIT LAMNALCO 26.06.22 17.08.22
SBM
Chief Hose Handling, Basrah Oil
SL KITE TUGBOAT 169 / 1264 kw Officer Assist Tanker SMIT LAMNALCO Terminal - IRAQ 15.05.22 24.06.22
SBM
Chief Hose Handling, Basrah Oil
SL KESTREL TUG BOAT 168 / 1750 kw Officer Assist Tanker SMIT LAMNALCO Terminal - IRAQ 15.01.22 15.04.22
SBM
Chief Hose Handling, Basrah Oil
SL KESTREL TUG BOAT 168 / 1750 kw Officer Assist Tanker SMIT LAMNALCO Terminal - IRAQ 10.07.21 03.12.21
SBM
Chief Hose Handling, Basrah Oil
SL KIWI TUG BOAT 120 / 2500 kw Officer Assist Tanker SMIT LAMNALCO Terminal - IRAQ 15.02.21 31.05.2021
SBM
Chief Hose Handling, Basrah Oil
SL KESTREL TUG BOAT 168 / 1750 kw Officer Assist Tanker SMIT LAMNALCO Terminal - IRAQ 28.08.20 11.12.2020
SBM
49,214 T Barge Gas Exploration
FLOATING PT. Samudera
FPU Jangkrik Supervi Macassar Strait 30.05.17 31.07.2020
BARGE Indonesia
sor
Chief Running Cargo,
1160 / 4750 MUBARRAZ Field -
ARINA QUEST AHTS Officer Supply, Rig MARCAP 13.07.16 10.10.16
HP UAE (ADOC)
Move

Revision 00. Original Date: 15/09/2015. Version date: N/A.

Prepared by: ALLIANZ QHSE Manager. Approved by: ALLIANZ General Manager. Validated by: ALLIANZ QHSE Manager. 4 /5
 CREW INFORMATION FORM
ALLIANZ-FRM-0202.14

1537 / 5150 Chief Supply, Running

LION KING AHTS – DP 1 OSM Kemaman, Labuan 07.07.15 10.10.15
HP Officer Cargo
1537 / 5150 Chief Supply, Running
LION KING AHTS – DP 1 OSM Kemaman, Labuan 04.03.15 09.05.15
HP Officer Cargo
Chief Anchor Job,
1731 / 5000 KEMAMAN (Coastal
TRINE K AHTS – DP 1 Officer Supply, Rig RK OFFSHORE 19.05.14 18.09.14
HP Energy)
Move
Chief Supply, Running
KEMAMAN
1537 / 5000
LION KING AHTS – DP 1 Officer OSM (PETRONAS 20.12.13 28.02.14
HP Cargo, Survey CARIGALI)
Chief Anchor Job, KEMAMAN
1731 / 5000
TRINE K AHTS – DP 1 Officer Supply, Rig RK OFFSHORE (PETRONAS 29.06.13 23.10.13
HP
Move CARIGALI)
1470 / 5000 Chief Survey, Running BINTULU (Asian
JUL SOFUS K AHTS – DP 1 RK OFFSHORE 02.03.13 08.05.13
HP Officer Cargo caliber)
TANJUNG 1669 / 5000 Chief Supply, Running Kemaman (EXXON
AHTS ICON OFFSHORE 24.11.12 09.02.13
PUTERI 2 HP Officer Cargo MOBIL)
Chief
VOS 1772 / 5000 Officer Supply, Running Songkhla
AHTS VROON OFFSHORE 29.01.12 31.05.12
OLYMPIAN HP Cargo (CHEVRON)

ARMADA 2183 / 8000 Chief Static Tow, Nigeria (ADDAX

AHTS – DP 1 BUMI ARMADA 24.05.11 06.09.11
TUAH 83 HP Officer Running Cargo Company)
1160 / 5000 Chief Supply, Running GULF MARINE
ATLAS 5502 AHTS Abudabi (ADOC) 06.02.11 23.04.11
HP Officer Cargo SERVICES
ARMADA 1333 / 5000 Chief Static Tow, Nigeria (AFREN
AHTS BUMI ARMADA 21.08.10 30.11.10
TUAH 22 HP Officer Running Cargo Company)
ARMADA 1333 / 5000 Chief Static Tow, Nigeria (AFREN
AHTS BUMI ARMADA 20.03.10 30.06.10
TUAH 22 HP Officer Running Cargo Company)

Revision 00. Original Date: 15/09/2015. Version date: N/A.

Prepared by: ALLIANZ QHSE Manager. Approved by: ALLIANZ General Manager. Validated by: ALLIANZ QHSE Manager. 5 /5