IMO FAL Form 5

IMO CREW LIST Form CRM 35 S.L. Customs - Prev 6

Arrival x Departure Page No. 1

1. Name Of Ship / Call Sign: 2. Port of Arrival: 3. Date of Arrival

MT SEI PAKNING / PODV DUMAI 01 Februari 2019

4. Nationality Of Ship: 5. Departure port .: 6. Nature, No. of identify document:

INDONESIA TANJUNG MANGGIS Passport & Seaman Book

7 8a. 8b. 9 10 11 6a. 6b.
Sign On Date
Date and SEAMAN BOOK PASSPORT
No. Full Name Sex Rank Nationality Expire
7 8 9 11 Place of birth 6a. Date 6b. Expire Date
19-Januari-1974 E 026813 C 0544584 10-Nov-2018
1 Budi Hariyanto M Master Indonesian Temanggung 11-Nov-2020 28-August-2023 Kepulauan Seribu
E 098374 B 0492994
28-July-1972 04-January-2019
2 Eko Arrivianto M Chief Off. Indonesian Jakarta
21-July- 13-
Kalbut
### 2019 Februari-2020
23-May-1983 A 8790200
E 108659 28-April-2018
3 Ervan Hardiansyah M 2nd Off. Indonesian 19-August-2019
07-August-
Cilacap
Garut 2019
27-April-1993 A 026544 07- B 4341055 24- 06-Oct-2018
4 Ari Kuswanto M 3rd Off. Indonesian Surabaya May-2019 June-2021 Kepulauan Seribu
09-December-1994
D 075152 B 1490320 09-May-2018
5 Rudi Setiawan M Junior Off. Indonesian 05-October-2020 22-June-2022 Cilacap
Temanggung
20-October-1963 F 124987 X 336229 04-January-2019
6 Sudaryanto P M Chief Eng. Indonesian Jakarta 15-March-2021 05-July-2022 Kalbut

14-Dec-1975 D 063343 B 5770637 17-Dec-2018

7 Aco Akbar Masud M 2nd Eng. Indonesian Ujung Pandang 06-April-2020 27-Februari-2019 Kalbut
C 047284
29-May-1984 B 1994828 07-April-2018
8 Dwi Wahyu Utomo M 3rd Eng. Indonesian Demak
10-March- 11-September-2020 Kepulauan Seribu
2019
C 044430 B 4731179
19-Desember-1985 28-May-2018
9 Iwan Hadinata M 4th Eng. Indonesian Jakarta
24-March- 26-August-
Kepulauan Seribu
2021 2021
A 9041405
22-February-1969 F 107614 18-April-2018
10 Marjain M Elect Eng. Indonesian Magetan 04-February-2020
08-September-
Kepulauan Seribu
2019
07-November-1977 D 083010 B 1112247 28-May-2018
11 Tony Kadir Doenggio M Pumpman Indonesian Surabaya 14-September-2020 25-June-2020 Kepulauan Seribu
E 126428
17-March-1963 C 0253701 28-May-2018
12 Ikhrodi Muhammad Nur M Bosun Indonesian Kota Agung
07-October-
15-May-2023 Kepulauan Seribu
2019
B 054799 B 7161410
08-August-1973 28-May-2018
13 Ramsel Kamea M AB Indonesian Binuang
07-May- 16-
Kepulauan Seribu
24-August-1972 2020 May-2022
C 000213
B 5770914 09-Sept-2018
14 Ismail Hidayat M AB Indonesian 15-
29-DEC-2021 Cilacap
August-2020
Bitung C 0441127
07-July-1985 C 083689 12-June-2018
15 Amiruddin M AB Indonesian Alesilurung 14-August-2021
14-May-
Kepulauan Seribu
2023
20-June-1980 F 030757 B 6066005 28-May-2018
16 Johnny Kaunang M OS Indonesian Jayapura 13-June-2020 02-February-2022 Kepulauan Seribu
19-November-1970 E 156274 B 606573 18-April-2018
17 Eko Subowo M Fitter Indonesian Magelang 04-February-2020 06-February-2022 Kepulauan Seribu
B 4526785
31-May-1979 F 124987 04-January-2019
18 Herry Triono M Motorman Indonesian Magelang 15-Maret-2021
01-Agustus-
Kalbut
2021
01-February-1972 B 023331 B 3000021 28-May-2018
19 Swandi Siringoringo M Motorman Indonesian Holbung 03-December-2019 14-January-2021 Kepulauan Seribu
24-May-1972 E 140902 A 9166751 18-April-2018
20 Jemi M Motorman Indonesian Jakarta 06-January-2020 24-September-2019 Kepulauan Seribu
A 8438811
E 018680
12-October-1974 30-June-2019 28-May-2018
21 Heintje Recky Victor T. M Chief Cook Indonesian Manado
11-
Kepulauan Seribu
October-2018
15-July-1978 C 047104 B 6971789 18-April-2018
22 Andri Suswanto M Messman Indonesian Jakarta 06-March-2021 07-April-2022 Kepulauan Seribu
09-September-1996 E 130709 B 5446101 18-April-2018
23 Muhammad Aldo Dany P. M Deck Cadet Indonesian Kudus 25-October-2019 29-November-2021 Kepulauan Seribu

27-June-1997 F 028605 B 7294933 18-April-2018

24 Agus Puguh Irawan M Engine Cadet Indonesian Pati 04-July-2020 17-June-2022 Kepulauan Seribu

Total Crew : 24 Person ( Included Master )

Capt. Budi Hariyanto

Master : Signature ________________________ Date _______________