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Entry Data Peserta Pelatihan Keterampilan
11 April 2021
DATA PESERTA
Nomor ID KTP / NIK
*
Nama Peserta
*
Tempat Lahir
*
Tanggal Lahir
*
Jenis Kelamin
*
LAKI-LAKI
PEREMPUAN
Nama Ibu Kandung
*
Pendidikan Terakhir
*
Agama
*
ISLAM
KATHOLIK
PROTESTAN
BUDHA
HINDU
KHONG HU CHU
Kewarganegaraan
*
WNI
WNA
Alamat Lengkap
*
No Handphone
Alamat E-mail
*
Program Diklat
*
BASIC SAFETY TRAINING ( BST )
PERSONAL SURVIVAL CRAFT RESCUE BOAT ( PSCRB )
MEDICAL FIRST AIDS ( MFA )
MEDICAL CARE ( MC )
ADVANCED FIRE FIGHTING ( AFF )
RADAR SIMULATOR ( RS )
ARPA SIMULATOR ( AS )
SECURITY AWARENESS TRAINING ( SAT )
SECURITY SHIP OFFICER ( SSO )
GENERAL OPERATION CERTIFICATE - GLOBAL MARITIME DISTRESS SAFETY SYSTEM ( GOC - GMDSS )
ELECTRONIC CHART DISPLAY INFORMATION SYSTEM ( ECDIS )
BRIDGE RESOURCE MANAGEMENT ( BRM )
ENGINE RESOURCE MANAGEMENT ( ERM )
CROWDED MANAGEMENT TRAINING ( CMT )
INTERNATIONAL SAFETY MANAGEMENT CODE ( ISM-CODE )
BASIC TRAINING OIL CHEMICAL TANKER ( BTOCT )
BASIC TRAINING LIQUID GAS TANKER ( BTLGT )
SECURITY TRAINING - SECURITY DESIGN SEAFARERS DUTIES ( SDSD )
CRISIS MANAGEMENT AND HUMAN BEHAVIOR TRAINING ( CMHBT )
FAST RESCUE BOAT ( FRB )
PASSENGER SAFETY, CARGO SAFETY AND HULL INTEGRITY ( PSCSHI )
ADVANCED OIL TANKER CARGO OPERATIONS ( AOTCO )
ADVANCE CHEMICAL TANKER ( ACT )
ADVANCE LIQUID GAS TANKER CARGO OPERATIONS ( ALGTCO )
TRAINING FOR MASTER AND OFFICERS IN CHARGE OF A NAVIGATIONAL WATCH ON BOARD OFFSHORE SUPPLY
ANCHOR HANDLING TUGBOAT SUPPLY ( AHTS )
INTERNATIONAL MARITIME DANGEROUS GOODS CODE ( IMDG CODE )
TRAINING OF OFFICERS AND RATINGS RESPONSIBLE FOR CARGO HANDLING ON SHIPS CARRYING DANGEROUS AND HAZA
BASIC SAFETY TRAINING ( BST ) KAPAL LAYAR MOTOR ( KLM )
HIGH SPEED CRAFT ( HSC ) BREVET A
HIGH SPEED CRAFT ( HSC ) BREVET B
FAMILIARIZATION HIGH SPEED CRAFT ( HSC )
REVALIDASI DIKLAT KETERAMPILAN PELAUT ( DKP )
CARGO CRANE OPERATOR
TALLYMAN OPERATOR
FORKLIFT OPERATOR
WELDING
ORU
Tanggal Diklat
*
PEMBERKASAN
(Berkas bertipe .jpg dan kapasitas max 2 Mb)
Fotocopy ijazah umum / sertifikat CoC
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Fotocopy akte kelahiran
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Fotocopy KTP atau Kartu Keluarga (KK)
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Sertifikat asli dan fotocopy warna sertifikat yang direvalidasi
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Fotocopy warna sertifikat BST
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Pas foto terbaru hitam putih dengan tulisan Poltekpel Banten ukuran 3x4 cm
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Surat keterangan tidak mampu (SKTM) dari Kelurahan/desa bagi peserta CSR/DPM
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Surat keterangan baca tulis dari Kelurahan/desa bagi peserta CSR/DPM
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Surat Pernyataan
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-=Download Surat Pernyataan=-
Surat keterangan sehat / sertifikat kesehatan yang masih berlaku
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Surat Masa Layar asli & fotocopy yang dikeluarkan oleh Syahbandar / Adpel**
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SKCK Asli dan fotocopy dari Kepolisian bagi peserta Rating Forming dan Able Seaferer
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Ket :
* Wajib Diisi
**untuk revalidasi TF ke BOCT atau BLGT, diklat Rating Forming atau Able Seafarer dan SCRB
