Form 22

IMMIGRATION ACT
(CHAPTER 133)

IMMIGRATION REGULATIONS
CREW LIST

Name of Vessel / Nama Kapal : LOGINDO ENERGY

Gross Tonage / GT Kapal
Agent in Port / Keagenan
Owner's / Pemilik
Date Of Arrival / Tanggal Tiba
Date Of Departure / Tanggal Berangkat
: 3594
:
: PT. LOGINDO SAMUDRAMAKMUR TBK.
: Last Port / Pelabuhan Sebelumnya :
: Next Port / Pelabuhan Selanjutnya :

No. Name / Nama Awak Sex / Date of Birth / Nationality / Travel Document No. / Doc.Of Travel Expired / Duties on Board / Seaferer Code / No. PKL Date of Sign On / Certificate / Certificate No. / NIK UNTUK WNI VAKSIN
Jenis Kelamin Tanggal Lahir Kebangsaan No. Buku Pelaut Tanggal Berakhir Buku Pelaut Jabatan Kode Pelaut Tanggal Sign On Sertifikat Ijazah Pelaut No. Sertifikat Ijazah Pelaut PASSPORT UNTUK WNA
1 YANCE AKBAR M Sabang, 19/01/1979 Indonesian G 044421 3/18/2024 MASTER 6200125062 AL.524/408/10/SYB.TPK/22 3/8/2022 ANT - I 6200125062N10114 3271051901790004 SUDAH
2 SUGIARTO M Jakarta, 29/09/1981 Indonesian F 249319 7/5/2024 CH OFFICER 6200142834 AL.524/466/10/SYB.TPK/22 9/5/2022 ANT - I 6200142834N10116 3216062909810021 SUDAH
3 MAGISTER MANURUNG M Medan, 20/07/1993 Indonesian G 015646 7/27/2023 2ND OFFICER 6201334493 AL.524/1977/9/SYB.TPK/22 6/24/2022 ANT - II 6201334493N20121 1208062007930002 SUDAH
4 HENDRA SITANGGANG M Jakarta, 22/8/1979 Indonesian F 214171 2/1/2024 CH. ENGINEER 6200062132 AL.524/467/10/SYB.TPK/22 3/15/2022 ATT - I 6200062132T10114 3175072208790002 SUDAH
5 FERNANDO SIMATUPANG M Batam, 27/05/1988 Indonesian F 112464 2/22/2025 2ND ENGINEER 6200391647 AL.524/406/10/SYB.TPK/22 9/5/2022 ATT - II 6200391647T20115 2171092705880005 SUDAH
6 DIRGANTARA M Palembang, 14/09/1982 Indonesian F 004301 27/03/2024 3RD ENGINEER 6201025254 AL.524/468/10/SYB.TPK/22 7/12/2022 ATT - I 6201025254T10122 1607011409820006 SUDAH
7 STEVEN HENRY MAULANY M Ambon, 25/04/1970 Indonesian F 239169 5/16/2024 BOSUN 6200034894 AL.524/407/10/SYB.TPK/22 6/15/2022 RATING 6200034894340120 3275042504700017 SUDAH
8 IZAAC PAULUS SOPACUA M Ambon, 5/02/1958 Indonesian C 076923 8/25/2024 ELECTRICIAN 6201000472 AL.524/1177/4/SYB.TPK/22 18/04/2022 ATTD 6201000472T60103 3275030502580009 SUDAH
9 JENI DAHLAN M Sukabumi, 24/12/1986 Indonesian F 004181 3/27/2024 AB 6201114268 AL.524/471/10/SYB.TPK/22 3/15/2022 ANT - V 6201114268N53822 3320233241286003 SUDAH
10 RONNY M Sabang, 18/02/1982 Indonesian F 208002 11/06/2024 AB 6201667383 AL.524/469/10/SYB.TPK/22 4/18/2022 RATING 6201667383340710 6472041802820005 SUDAH
11 FIRDAUS M Surabaya, 11/12/1977 Indonesian E 110371 8/23/2023 AB 6200077358 AL.524/470/10/SYB.TPK/22 9/5/2022 ANT - V 6200077358M50617 7316071112770001 SUDAH
12 IRAWAN HARIANTO M Surabaya ,14/09/1979 Indonesian F 045976 7/3/2024 OILER 6200319709 AL.524/474/10/SYB.TPK/22 9/5/2022 RATING 6201667383340710 7602121409790002 SUDAH
13 RIDWAN M Ujung Pandang, 28/01/1982 Indonesian F 018426 8/12/2024 OILER 6200467027 AL.524/473/10/SYB.TPK/22 9/5/2022 ATT - III 6200467027T30420 7306082801820015 SUDAH
14 ALDI ALATTAS M Palopo, 20/02/1984 Indonesian F 263043 22/01/2024 OILER 6200140632 AL.524/472/10/SYB.TPK/22 3/15/2022 ATT - V 6200140632T53822 3172032002840012 SUDAH
15 ABDUL KHALIK M Botta, 15/09/1979 Indonesian G 108108 18/11/2024 COOK 6200516967 AL.524/1242/08/SYB.TPK/22 8/23/2022 RATING 6200516967340716 3172021509790009 SUDAH
16 GILANG ENGGAR ALIKA PUTRA M Kediri, 12/08/2001 Indonesian H 022058 4/4/2025 DECK CADET 6212143184 AL.524/130/09/SYB.TPK/22 9/5/2022 BST 6212143184010520 3506261208010002 SUDAH
17 DIKY FAHRULI M Bojonegoro, 23/12/2001 Indonesian G 066805 01/04/2025 ETO CADET 6212133942 AL.524/131/9/SYB.TPK/22 9/5/2022 BST 6212133942010520 3522142312010004 SUDAH

Person included master.

Total Crews / Total Awak : 17

Acknowledge ________________, Year

Master

Capt. Yance Akbar Manager