PERSONAL DATA FORM

PERSONAL DETAILS
Name of Agency PT. RATU OCEANIA RAYA JAKARTA
Position of Crew STATE ROOM STEWARD
Last Name as in Passport WAHED
First name as in Passport ABDUL
Middle name as in Passport
Gender MALE
Date of Birth SEPT, 28 1978
Place of Birth BANGKALAN
Country of Birth INDONESIA
Nationality INDONESIA
Residence INDONESIA
IF residing in US, social security number
Marital status MARRIAGE
No. Of Children 1
Hair Color BLACK Eye Color BLACK
Height (cm) 167 Weight (lbs) 67
Date of Medical
ADRESS DETAILS
Adress JL. RAYA SABIYAN RT 02 RW 01 DESA SABIYAN
Town/City BANGKALAN
Postal code 69113 State JAWA TIMUR
Country Indonesia
Mobile/ Telephone (with international dialing code) 6281213172065
E-mail adress abdulwahed2121@gmail.com
Nearest international airport to final destination JUANDA SURABAYA
PASSPORT DETAILS
Passport Number B 7689565
Issue country Indonesia
Issue date 18-Aug-17
Expiration date 18-Aug-22
SEAMAN'S BOOK DETAILS
Seaman's Book Number
Issuing Country Indonesia
Expiration date
EMERGENCY CONTACT DETAILS
PLEASE GIVE DETAILS OF SOMEONE WHO CAN BE CONTACTED IN THE CASE OF AN EMERGENCY.
THIS SHOULD NOT BE ANYONE TRAVELLING ONBOARD WITH YOU.
Name RATNA WAHYUNINGSIH
Relationship WIFE
Mobile/ Telephone (with international dialing code) 6282130055859
E-mail adress:
Address: JL. RAYA SABIYAN RT 02 RW 01 DESA SABIYAN
Town/ City: BANGKALAN
Postal code 69113 State JAWA TIMUR
Country Indonesia
CUSTOM'S DECLARATION
Please indicate how many of each item you are bringing on board with you. This information will be used for Custom's Purposes Only.
In the event that you purchase any of the items listed below during your contract you should advise the Crew Purse,
in order that the necessary amendment can be made to your Declaration.
Camera Liquor ( Sealed) Speaker
Camera Accessories Mobile Phone Video Camera
Cigarettes (Max. 200) Musical Instrument Sunglasses
Jewelry (No Costume) Perfume (Not Open) Watches
Laptop/Tablet

SIGNATURE OF CREW MEMBER DATE CREW PURSER

PLEASE COMPLETE THE SIGN ON FORM AND BRING IT WITH YOU, COMPLETELY FILLED OUT BY THE TIME YOU ARRIVE ON BOARD.
* MANDATORY TO UPDATE