Please type or write clearly in capital letters.
Do not leave
any space blank. Use NIL or N/A where applicable.
Programme: Japan- Singapore Partnership Programme for the 21st Century (JSPP21)
Course Title: Maritime Safety Management
Course Dates: 10 to 14 November 2014
Applicant's Particulars
Salutation
Dr/Mr/Mrs/Ms/Others (please specify)
Family Name
AGAM
Given Name
HERIWANSYAH PUTRA
Nationality
INDONESIA
Passport Number
Passport Expiry Date
A 0268084
MALE
Gender
Representing the
Government of
(dd/mm/yy)
(if different from
nationality)
Ethnic Group
ACEH
LIEUTENANT COMMANDER
Current Job Title
06-08-1969
09-06-2016
Date of Birth (dd/mm/yy)
Marital Status
MARRIAGE
Dietary Restrictions
(if any)
VEGETARIAN
Religion
CHRITSTIAN PROTESTAN
Airport of Departure to
JAKARTA (CGK)
Singapore
Home Address
Country
Postal Address
(Street,
House/Block,
Unit, etc)
INDONESIA
City/Town
MANADO
Postal Code
95129
KOMPLEKS AL NO.B4, KAIRAGIWERU MANADO
Country
Code
Tel No.
NORTH
SULAWESI
State/Province
+62
Area
Code
0431
Number
Country
Area
Code
Code
Number
852329
Mobile
+62
81356808992
State/Province
NORTH
SULAWESI
City/Town
MANADO
Postal Code
95119
Office Address
Country
Postal Address
(Street,
House/Block,
Unit, etc)
Tel No.
Primary Email
INDONESIA
JL. DIPONEGORO NO. 126, TELING MANADO
Country
Code
Area
Code
+62
0431
Number
[email protected]
Country
Area
Code
Code
Number
Fax No.
+62
Secondary
Email
[email protected]
0431
852330
Person to be notified in case of emergency
Name
Address
Mrs. ALFIRA A. ASSA
Relationship
KOMPLEKS AL NO. B4
Contact
Number
Email
KAIRAGIWERU, MANADO
WIFE
Country Code
+62
Area Code
Number
82193289976
[email protected]
NOTE: This application form should be duly completed and endorsed by the Ministry of Foreign Affairs or the National Focal Point
for Technical Assistance in your country. Forms which are incomplete or not endorsed will not be accepted.
Employment History (starting with present position, i.e. in reverse chronological order)
Organisation
Designation
Department
Unit Duties of
Leutenant
Indonesian Maritime
Coordinating Maritime Commander
Coordinating Board Security team
Navy
Navy
Navy Based VIII
Security &
Invesment of
Maritime
Battle Ship (KRI)
Nature of Job
From
To
(dd/mm/yy)
(dd/mm/yy)
PRESENT
2011
(2014)
Commander of
Denma
2008
2010
Chief of Assistant
Intelegent
1999
2002
Chief of Devision
Electricity
Officer
1992
1995
Major
Navy
Head of Logistic
Supporting area
Educational Qualifications (starting with highest qualification attained, i.e. in reverse chronological
Orde Educational Qualification
Attained
Educational Institution
Technigue Magister of Science
From
(dd/mm/yy)
To
(dd/mm/yy)
Elementary School
1976
1982
Junior High School
1982
1985
Senior High School
1985
1988
Bachelor Degree
1996
1999
Master Degree
2009
2011
Professional Qualifications
Description of Qualification
Date Attained
Previous Attendance
Have you previously attended any courses sponsored under the Singapore
Cooperation Programme? If yes, please state the name and date of course(s)
Indonesia Singapore Training Cooperation
1.
2.
Eagle Singapore Indonesia Training Cooperation
Yes/No
1994
1994
Experience and Training Requirements
Please write briefly on your working experience and training requirements.
Copies of the relevant supporting documents (e.g. educational certificates, testimonials) should be attached.
1. TNI AL/AAL-38 (Academy of Navy)
(1989-1992)
2.
Basic Course of Intelegent Officer ABRI-27
3.
STTAL Angkatan XVIII
4.
Combating Weapon Mass Destruction Course at Maritime Ports
(1995)
(1996-1999)
(2013)
NOTE: This application form should be duly completed and endorsed by the Ministry of Foreign Affairs or the National Focal Point
for Technical Assistance in your country. Forms which are incomplete or not endorsed will not be accepted.
APPLICANTS DECLARATION
I,
HERIWANSYAH P. of
Name of applicant
BAKORKAMLA-INDONESIA
Representing Country
Declare that:
(a) all information provided is true, complete and accurate to the best of my belief and knowledge, and
that I have not wilfully suppressed any material facts;
(b) I am medically fit and free from any medical problems which may impair my ability to attend and
complete the training in Singapore; and
(c) (For pregnant female applicants only): I am______ months pregnant and am/am not certified by a
qualified doctor to be medically fit and in good health to travel and attend the training in
Singapore; and
(d) I will be personally liable for all medical expenses incurred during my stay in Singapore, other than
those covered under the Group Personal Accident Insurance and Group Hospital & Surgical Insurance
policy.
(All successful participants are covered under Group Personal Accident and Group Hospital &
Surgical Insurance. The Group Hospital & Surgical Insurance does not cover any pre-existing
conditions/illnesses or any outpatient medical/dental treatment. Participants are personally liable for
all medical expenses beyond what is covered by the insurance policy. As the coverage is limited,
participants are advised to make their own arrangements to obtain adequate medical insurance
coverage for their stay in Singapore.)
Upon successful selection for the training award, I undertake to:
(a) carry out instructions and abide by such terms and conditions as may be stipulated by the
nominating and host governments in respect of this training course;
(b) abide by the rules and regulations of the training institution in which I undertake to study in or be
trained under;
(c) submit/present any report which may be required;
(d) refrain from engaging in political activities and any form of employment for profit or gain;
(e) return to my home country upon completion of the training; and
(f) discontinue the course should I be found guilty of misconduct or be medically unfit.
I fully understand that if I fail to comply with the terms and conditions of the training award, and/or any
of the above declarations are found to be untrue, the award will be terminated with immediate effect
and I will be liable to depart from Singapore at my own expense.
10 September 2014
Date
Signature of applicant
NOTE: This application form should be duly completed and endorsed by the Ministry of Foreign Affairs or the National Focal Point
for Technical Assistance in your country. Forms which are incomplete or not endorsed will not be accepted.
TO: GOVERNMENT OF THE REPUBLIC OF SINGAPORE
Dear Sir
LETTER OF INDEMNITY
In consideration of your allowing me to do my training with the relevant Government
departments/statutory boards/institutions in Singapore, I,
HERIWANSYAH P.
, of
Passport Number
A 0268084
of
INDONESIA
, hereby
declare that I shall be personally liable for and shall indemnify the Government of the Republic of
Singapore and the Japan International Cooperation Agency against all liabilities, claims, losses,
demands,actions, suits, proceedings, costs or expenses whatsoever arising under any statute or
common law which may be made or taken against the Government of the Republic of Singapore and
the Japan International Cooperation Agency or incurred or becaome payable by the Government of the
Republic of Singapor and the Japan International Cooperation Agency in respect of any medical illness,
personal injury, (whether fatal or otherwise) to or the death of any person or in respect of any injury or
damage whatsoever to any property, real or personal arising out of or in the course of or by reason of
my carelessness or negligence, omission or default during my training with the relevant Government
departements/statutory boards/institutions in Singapore.
Dated this _______day _____________________of 2014/2015
Signed by____________________________________
Signature of applicant
HERIWANSYAH PUTRA
Name of applicant
in the presence of _____________________________
Signature of witness
Name and designation of witness
NOTE: This application form should be duly completed and endorsed by the Ministry of Foreign Affairs or the National Focal Point
for Technical Assistance in your country. Forms which are incomplete or not endorsed will not be accepted.
TO BE COMPLETED BY THE NOMINATING GOVERNMENT
Applicant's Proficiency in the English Language
Excellent
Good
Fair
Basic
Good
Fair
Basic
Spoken
Written
Applicant's Fitness Level
Excellent
Health
Reasons for applicant's selection
To get more knowledge about Maritime Security
The post which the applicant will be required to fill upon satisfactory
completion of training
Experiences and for career
Relevance of the course to applicant's job
Because my jobs are guarding the security of maritime
NOTE: This application form should be duly completed and endorsed by the Ministry of Foreign Affairs or the National Focal Point
for Technical Assistance in your country. Forms which are incomplete or not endorsed will not be accepted.
TO BE COMPLETED BY THE NOMINATING GOVERNMENT
OFFICIAL DECLARATION
On behalf of the Government of __________________________, I, ________________________,
Country
Name of official
certify that:
(a) I have examined the educational, professional or other certificates quoted by the applicant in this
form and I am satisfied that they are authentic and relate to the applicant;
(b) The applicant is medically fit and free from infectious disease and that, having regard to his/her
physical and mental history, there is no reason to suppose that the applicant is other than fit to
undertake the journey to Singapore and to remain in Singapore for the duration of training;
(c) Should the nominee seek medical consultation/treatment during his period of stay in Singapore, he
would be personally liable for all medical expenses incurred, other than those covered under the Group
Personal Accident Insurance and Group Hospital & Surgical Insurance policy; and
(d) The applicant has attained a level of proficiency in both spoken and written English to enable
him/her to follow the course of study/training for which he/she is being nominated.
I nominate (Dr/Mr/Mrs/Ms*) _______________________ holding Passport No._______________ for
the training course.
Name and Designation
Signature
Name of Organisation
___________-_________-____________________
Country code Area code
Office tel no.
Email Address
___________-_________-____________________
Country code Area code
Office fax no.
Endorsement by the nominating countrys Ministry of Foreign Affairs or the National Focal Point for
Technical Assistance:
Name
Email Address
(Ministrys Official Stamp)
Designation
Name of Organisation
Signature
___________-_________-________________________
Country code Area code
Office tel no.
___________-_________-________________________
Country code Area code
Office fax no.
NOTE: This application form should be duly completed and endorsed by the Ministry of Foreign Affairs or the National Focal Point
for Technical Assistance in your country. Forms which are incomplete or not endorsed will not be accepted.
