Form 22

IMMIGRATION ACT
(CHAPTER 133)
IMMIGRATION REGULATIONS
CREW LIST
Name of Vessel / Nama Kapal : MT. MARLIN 88
Gross Tonage / GT Kapal : 28,480 T
Agent in Port / Keagenan : PTK
Owner's / Pemilik : PT. PATRIA NUSA SEGARA
Date Of Arrival / Tanggal Tiba 2-Aug-23 Last Port / Pelabuhan Sebelumnya WAYAME
Date Of Departure / Tanggal Berangkat TBA Next Port / Pelabuhan Selanjutnya TBA

Sex / Date of Birth / Nationality / Travel Doc. No. / Doc.Of Travel Expired / RANK / Seaferer Code / Date of Sign On / Certificate / Certificate No. /
No. Name / Nama Awak Jenis Kelamin Tanggal Lahir Kebangsaan No. Buku Pelaut Tanggal Berakhir Buku Pelaut Jabatan Kode Pelaut No. PKL Tanggal Sign On Sertifikat Ijazah Pelaut No. Sertifikat Ijazah Pelaut
1 CARLES YACOB HARINDAH M 10-Jul-1974 INDONESIA G 075447 21-Apr-24 MASTER 6200008944 09/03/BPN,23 9-Mar-2023 ANT I 6200008944N10121
2 HAPIT HALAKIN M 21-Oct-1975 INDONESIA F 253927 02-Oct-24 CH/OFF 6200073073 AL.524/566/7/SYB.TPK/2022 12-Jul-2022 ANT- II 6200073073N20418
3 TETO MIDRI M 20-Aug-1994 INDONESIA G 078747 29-Jul-24 2ND/OFF 6202006761 AL.524/SYB.TPK.23 7-Jun-2023 ANT- II 6202006761N20119
4 MUHAMMAD SYAHRUR RIADHY M 4-May-1995 INDONESIA H 032811 17-Jun-25 3RD/OFF 6211579317 AL.524/24/12/KSOP.CLP.23 12-Jun-2023 ANT - III 6211579317N30119
5 RIDHO FAJRIANDA M 3-Mar-2000 INDONESIA F 212926 16-Jan-2024 4TH/OFF 6211811773 - 15-Jul-2023 ANT- III 6211811773N30121
6 LOREN NABABAN M 10-Sep-1986 INDONESIA F 38589 28-Jan-2025 CH/ENG 6200257317 AL.524/24/11/KSOP.CLP.23 12-Jun-2023 ATT-I 6200257317T10116
7 LASMONO M 15-Nov-1988 INDONESIA F 125105 28-Jan-2025 2ND/ENG 6201196019 AL.524/116/6/SYB.TPK.23 7-Jun-2023 ATT-I 6201196019T10222
8 RAHMAT HIDAYAT M 27-Mar-1989 INDONESIA G 000194 28-Jan-25 3TH/ENG 6201291759 AL.524/95/8/UPP.BRG/2023 20-Jun-2023 ATT-I 6201291759T10120
9 TRIA SUPANDI M INDONESIA 4TH/ENG 10-Aug-2023
10 EDO FATAH HIDAYAT M 2-May-2000 INDONSESIA G 012310 6-Jul-25 5TH/ENG 6211937569 - 6-Aug-2023 ATT - III 6211937569T30322
11 AIDIL ROSAN M 31-Jul-1981 INDONESIA F 309003 6-Dec-24 ELECT 6201070514 AL.524/95/UPP.BRG/2023 22-Jun-2023 RAASE 6201070514423821
12 KARSONO M 5-Dec-1969 INDONESIA F 319706 6-Feb-25 BOATSWAIN 6200020697 - 6-Aug-2023 RAASD 6200020697340221
13 HARMAN M 25-Apr-1991 INDONESIA I 043801 12-May-26 PUMPMAN 6200564649 AL.524/142/6/SYB.TPK.23 7-Jun-2023 RAASD 6200564649340622
14 ANDHIKA JULFRIANO M 14-Jul-1984 INDONESIA F 231041 25-Apr-24 A/B 6201024506 AL.524/143/6/SYB.TPK.23 7-Jun-2023 RAASD 6201024506340217
15 MULIADI M 7-Jun-1981 INDONESIA F 147700 22-Apr-24 A/B 6201289003 11/03/BPN,23 9-Mar-2023 RAASD 6201289003340620
16 HUSNUL HOLIK M 4-Jun-1983 INDONESIA G 019615 30-May-25 A/B 6200204284 AL.524/114/VI/SKOP.BTN.23 7-Jun-2023 RAASD 6200204284340121
17 JOKO WASKITO M 23-Aug-1994 INDONESIA B 013477 23-May-24 O/S 6201399228 AL.524/95/10/UPP.BRG/2023 22-Jun-2023 RFPNW 6201399228330716
18 SUGENG RIYADI M 26-Jun-1992 INDONESIA F 327863 26-Aug-24 O/S 6211863795 AL.524/219/5/SYB.TPK.23 6-May-2023 RAASD 6211863795340521
19 DARMAWANSYAH M 23-Jan-1980 INDONESIA F 058169 26-Apr-24 FITTER 6201659076 08/03/BPN,23 9-Mar-2023 RAASE 6201659076420616
20 BANGUN RONALD SINAGA M 16-Dec-1981 INDONESIA E 139826 30-Mar-26 OILER 6201110273 AL.524/394/V/KSOP.BTN 24-May-2023 RAASE 6201110273420717
21 BUSTAMI M 10-Dec-1972 INDONESIA F 139675 11-May-25 OILER 6200086315 - 20-Jul-2023 RAASE 6200086315420719
22 INCE IRWAN M 27-Mar-1987 INDONESIA F 253899 18-Sep-24 OILER 6202082849 PK.524/14/03/KSOP.PBI.23 25-Mar-2023 RAASE
23 SYAHRUL MUNAZAR M 14-Feb-1999 INDONESIA F 284480 18-Aug-23 WIPER 6212014339 PK.524/07/01/KSOP.PBI.23 17-Jan-2023 ATT - IV 6212014339T43822
24 DADAN HIDAYAT M 20-Feb-1981 INDONESIA F 247578 23-Jun-24 COOK 6201661056 - 21-Jul-2023 RAASD 620661056340716
25 EKO ARI WIBOWO M 21-Apr-1987 INDONESIA H 085886 2-Dec-25 MESSMAN 6212262186 AL.524/130/05/SYB.TPK.23 5-May-2023 BST 6212262186010122
26 BORIS GELFAN SITOMPUL M 17-Oct-2002 INDONESIA H 045638 3-Jun-25 DECK CADET 6212137685 150/11/BPN22 9-Nov-2022 BST 6212137685010121
27 BAGAS NUGROHO PUTRA M 14-Mar-2002 INDONESIA H 074073 24-Mar-26 ENGINE CADET 6212143757 AL.524/117/6/SYB.TPK.23 7-Jun-2023 BST 6212143757012421

Total Crews / Total Awak : 27 Person included master.

Acknowledge 11-Sep-23
Harbour Master,

Capt. Carles Yacob Harindah

Master