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ANNEX - 01 Crew Particular Form Rev 0.0.doc II
ANNEX - 01 Crew Particular Form Rev 0.0.doc II
CREW PARTICULARS
Vessel Name Position
AB
Address / Overseas
Perumahan Taman Sari Hijau, Blok G7 No. 16 Tiban – Batam – Indonesia
DECLARATION
Have you ever been convicted of any criminal offence? Yes / No
Have you ever file for bankruptcy? Yes / No
Have you been hospitalized for more than 6 months? Yes / No
Have you ever been dismissed/suspended by other organization? Yes / No
I hereby certify that the above information is true to the best of my knowledge
and that I have not willfully suppressed any material facts