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    The document is an IMO FAL Form 5 for the ship MT. PETROSAMUDRA departing from Pulau Sambu, Indonesia to Jakarta, Indonesia on March 20, 2021. It lists 8 crew members including the master, chief officer, third officer, second engineer, and others. For each crew member it provides information such as name, sex, rank, nationality, place and date of birth, and details about their identification documents including passport and seaman book numbers and expiration dates.

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    The document is an IMO FAL Form 5 for the ship MT. PETROSAMUDRA departing from Pulau Sambu, Indonesia to Jakarta, Indonesia on March 20, 2021. It lists 8 crew members including the master, chief officer, third officer, second engineer, and others. For each crew member it provides information such as name, sex, rank, nationality, place and date of birth, and details about their identification documents including passport and seaman book numbers and expiration dates.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    22 views1 page

    Anti Gen

    Uploaded by

    Adam Alexander
    The document is an IMO FAL Form 5 for the ship MT. PETROSAMUDRA departing from Pulau Sambu, Indonesia to Jakarta, Indonesia on March 20, 2021. It lists 8 crew members including the master, chief officer, third officer, second engineer, and others. For each crew member it provides information such as name, sex, rank, nationality, place and date of birth, and details about their identification documents including passport and seaman book numbers and expiration dates.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    IMO convention on facilitation of International Maritime Traffic IMO FAL Form 5

    S.L. Customs - Prev 6

    Departure
    Arrival Page 1 of 1
    1. Name Of Ship : 2. Port of Arrival : 3. Date Of Arrival :

    MT. PETROSAMUDRA PULAU SAMBU , INDONESIA 20-Mar-2021


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

    JAKARTA - INDONESIA SIHANOUKVILLE , CAMBODIA -


    7 8a. 8b. 9 10 11 12 6a. 6b.
    Date and SEAMAN BOOK PASSPORT
    Certificate of
    No. Full Name Sex Rank Nationality
    Competency
    Place of birth Expire Date
    F 150527 Expire Date
    B 5632761
    30-11-1970
    1 Irwan Riyadi Kendek M Master Class I Indonesian Jakarta
    01-12-
    05-04-2022 2021
    E 041185 B 3690846
    19-03-1981
    2 Geral Fadjar Kennadi M Chief Off Class I Indonesian Jakarta
    30- 31-03-
    11-2022
    B 080376 2021
    22-10-1986 C 1977254
    3 Perik Hasiolan M 3rd Off Class III Indonesian Tanjung Karang 10-12-2023
    29-04-2023
    F 025100
    10-05-1974 C 4491332
    4 Usep Supriyatna M 2nd Eng Class I Indonesian Sumedang 23-07-2024
    19-05-2022
    E 064306 B 5383856
    20-02-1988
    5 Maidin Rudy Saimanto Simamora M SUP BST Indonesian Dolok Sait
    20-
    05-2021
    C 071995 10-11-2021
    B 5382719
    14-02-1977
    6 Heri Susanto M Electrician ETO Indonesian Jakarta
    18-06-
    2021
    E 120238 31-10-2021
    07-11-1971 B 8299161
    7 Udin Alamin M Oiler No. 1 ATT-D Indonesian Jakarta
    21-09-
    19-10-2022
    2021
    F 054384 B 5633655
    22-10-1962
    8 Adi Ruslian M Pumpman ANT-D Indonesian Pontianak
    15- 09-12-
    08-2022 2021
    E 052942 C 4493350
    03-06-1980
    9 Adolf Sopakuwa M Q/M ANT-D Indonesian Ihamahu
    12- 02-
    01-2023 08-2024
    C 1067998
    28-04-1987 E 040815
    10 Fadly Aprianto Abidin M Q/M ANT-D Indonesian Masohi 15-05-2021
    14-12-
    2023
    29-09-1984 F 064069
    B 5562844
    11 Ambri M Oiler ATT-D Indonesian 13-10-
    29-11-2021
    Walenrang 2022
    03-02-1973 F 006859
    C 3941943
    12 Juhamzah M Oiler ATT-D Indonesian 12-04-
    24-05-2024
    Bangkalan 2022

    Hotel Golden proun

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