Form 22

IMMIGRATION ACT
(CHAPTER 133)

IMMIGRATION REGULATION
CREW LIST

Name of Vessel / Nama Kapal : MV. DEWI AMBARWATI

Gross Tonage / GT Kapal : 19.000
Agent in Port / Keagenan : PT. GURITA LINTAS SAMUDERA
Owner's / Pemilik : PT. GURITA LINTAS SAMUDERA
Date Of Arrival / Tanggal Tiba : 01-MAR-2024
Date Of Departure / Tanggal Berangkat : 05-MAR-2024

No. Name / Nama Awak Sex / Date of Birth /

Jenis Kelamin Tanggal Lahir
1 BERLY KURNIAWAN M 9-Feb-1974
2 WALUYO SEBAYANG M 16-Nov-1982
3 M.KHIZAM BILAL M 21-Jun-1997
4 FATKU ROHZAK DWI YULIANTO M 5-Jan-1997
5 AYUDY SUSILO M 2-Dec-1983
6 FAUZI TAFTHOZANI M 27-Apr-1972
7 DORI PUTRA YANDA M 28-Aug-1993
8 AGUNG PRAYOGI M 15-Nov-1996
9 KARYADI M 29-Dec-1988
10 RASMAN M 27-Jan-1992
11 FENDI WAHYONO M 30-Oct-1989
12 EDI SUKMANA M 27-Feb-1983
13 ARIS M 17-Sep-1997
14 IRSAN M 13-Aug-1991
15 JULIUSMAN EFENDI M 26-Jul-1985
16 SALIMI M 14-Feb-1970
17 MUHAMAD ARIF NOVIYANTO M 11-Nov-1993
18 MUSTA'IN M 16-Sep-1983
19 ATENG ROMDONI M 20-May-1987
20 TED BAGANIA M 4-Mar-1977
21 AISYAH MALIKA F 28-Jul-2003
22 MOCH AKMAL NURHAKIM M 9-Aug-2002
Total Crews / Total Awak : Person included master.
 Form 22
IMMIGRATION ACT
(CHAPTER 133)

IMMIGRATION REGULATIONS
CREW LIST

SAMUDERA
SAMUDERA
Last Port / Pelabuhan Sebelumnya : AMAMAPARE
Next Port / Pelabuhan Selanjutnya : AMAMAPARE

Nationality / Travel Document No. / Doc.Of Travel Expired /

Kebangsaan No. Buku Pelaut Tanggal Berakhir Buku Pelaut
ID I.105323 18-Dec-2028
ID I.023245 2-Jul-2026
ID F.126599 20-Apr-2025
ID I.127647 25-Jan-2027
ID F.227396 4-Mar-2026
ID F.092123 16-Jan-2025
ID G.055233 7-Jun-2024
ID I.059974 4-Jul-2025
ID F.341350 10-Mar-2025
ID F.336533 29-May-2025
ID F.200752 6-Sep-2024
ID H.032835 15-Jun-2025
ID H.032836 15-Jun-2025
ID F.097001 8-Jan-2025
ID F.114174 15-Jan-2026
ID G.015737 27-Jul-2026
ID G.077719 18-Jun-2026
ID G.026761 8-Oct-2025
ID G.076219 11-May-2024
ID M.058204 6-Oct-2025
ID I.049985 17-May-2028
ID I.057550 8-Jun-2026
cluded master.
Duties on Board /
Jabatan
MASTER
CHIEF OFF
2ND OFF
3RD OFF
CHIEF ENG
2ND ENG
3RD ENG
4TH ENG
BOSUN
A/B 2
A/B 2
A/B 3
O/S 1
O/S 2
FITTER
OILER 1
OILER 2
OILER 3
CHIEF COOK
MESS BOY
CADET DECK
CADET ENG
KODE NEGARA NAMA NEGARA
AD ANDORRA
AE UNITED ARAB EMIRATES
AF AFGHANISTAN
AG ANTIGUA AND BARBUDA
AI ANGUILLA
AL ALBANIA
AM ARMENIA
AN NETHERLANDS ANTILLES
AO ANGOLA
AQ ANTARTICA
AR ARGENTINA
AT AUSTRIA
AU AUSTRALIA
AW ARUBA
AZ AZERBAIJAN
BA BOSNIA AND HERZEGOVINA
BB BARBADOS
BD BANGLADESH
BE BELGIA
BF BURKINA FASO
BG BULGARIA
BH BAHRAIN
BI BURUNDI
BJ BENIN
BM BERMUDA
BN BRUNEI DARUSSALAM
BO BOLIVIA
BR BRAZIL
BS BAHAMAS
BT BHUTAN
BV BOUVET ISLAND
BW BOTSWANA
BY BELARUS
BZ BELIZE
CA CANADA
CC COCOS (KEELING) ISLANDS
CD CONGO
CF CENTRAL AFRICAN REPUBLIC
CG CONGO
CH SWITZERLAND
CI COTE D'IVOIRE
CK COOK ISLANDS
CL CHILE
CM CAMEROON
CN CHINA
CO COLOMBIA
CR COSTA RICA
CU CUBA
CV CAPE VERDE
CX CHRISTMAS ISLAND
CY CYPRUS
CZ CZECH REPUBLIC
DE GERMANY
DJ DJIBOUTI
DK DENMARK
DM DOMINICA
DO DOMINICAN REPUBLIC
DZ ALGERIA
EC ECUADOR
EE ESTONIA
EG EGYPT
EH WESTERN SAHARA
ER ERITREA
ES SPAIN
ET ETHIOPIA
EU EROPA
FI FINLANDIA
FJ FIJI
FK FALKLAND ISLANDS (MALVINAS)
FM MICRONESIA
FO FAROE ISLANDS
FR FRANCE
GA GABON
GB UNITED KINGDOM
GD GRENADA
GE GEORGIA
GF FRENCH GUIANA
GH GHANA
GI GIBRALTAR
GL GREENLAND
GM GAMBIA
GN GUINEA
GP GUADELOUPE
GQ EQUATORIAL GUINEA
GR YUNANI
GS SOUTH GEORGIA AND THE SOUTH SANDWICH ISL
GT GUATEMALA
GU GUAM
GW GUINEA-BISSAU
GY GUYANA
HK HONG KONG
HM HEARD ISLAND AND MCDONALD ISLANDS
HN HONDURAS
HR CROATIA
HT HAITI
HU HUNGARY
ID INDONESIA
IE IRELAND
IL ISRAEL
IN INDIA
IO BRITISH INDIAN OCEAN TERRITORY
IQ IRAQ
IR IRAN
IS ICELAND
IT ITALY
JM JAMAICA
JO JORDAN
JP JAPAN
KE KENYA
KG KYRGYZSTAN
KH CAMBODIA
KI KIRIBATI
KM COMOROS
KN SAINT KITTS AND NEVIS
KP NORTH KOREA
KR SOUTH KOREA
KW KUWAIT
KY CAYMAN ISLANDS
KZ KAZAKSTAN
LA LAOS
LB LEBANON
LC SAINT LUCIA
LI LIECHTENSTEIN
LK SRI LANKA
LR LIBERIA
LS LESOTHO
LT LITHUANIA
LU LUXEMBOURG
LV LATVIA
LY LIBYAN ARAB JAMAHIRIYA
MA MOROCCO
MC MONACO
MD MOLDOVA
ME Montenegro
MG MADAGASCAR
MH MARSHALL ISLANDS
MK MACEDONIA
ML MALI
MM MYANMAR
MN MONGOLIA
MO MACAU
MP NORTHERN MARIANA ISLANDS
MQ MARTINIQUE
MR MAURITANIA
MS MONTSERRAT
MT MALTA
MU MAURITIUS
MV MALDIVES
MW MALAWI
MX MEXICO
MY MALAYSIA
MZ MOZAMBIQUE
NA NAMIBIA
NC NEW CALEDONIA
NE NIGER
NF NORFOLK ISLAND
NG NIGERIA
NI NICARAGUA
NL NETHERLANDS
NO NORWAY
NP NEPAL
NR NAURU
NU NIUE
NZ NEW ZEALAND
OM OMAN
PA PANAMA
PE PERU
PF FRENCH POLYNESIA
PG PAPUA NEW GUINEA
PH PHILIPPINES
PK PAKISTAN
PL POLAND
PM SAINT PIERRE AND MIQUELON
PN PITCAIRN
PR PUERTO RICO
PS PALESTINIAN TERRITORY
PT PORTUGAL
PW PALAU
PY PARAGUAY
QA QATAR
RE REUNION
RO ROMANIA
RS SERBIA
RU RUSSIAN FEDERATION
RW RWANDA
SA SAUDI ARABIA
SB SOLOMON ISLANDS
SC SEYCHELLES
SD SUDAN
SE SWEDEN
SG SINGAPORE
SH SAINT HELENA
SI SLOVENIA
SJ SVALBARD AND JAN MAYEN
SK SLOVAKIA
SL SIERRA LEONE
SM SAN MARINO
SN SENEGAL
SO SOMALIA
SR SURINAME
ST SAO TOME AND PRINCIPE
SV EL SALVADOR
SY SYRIAN ARAB REPUBLIC
SZ SWAZILAND
TC TURKS AND CAICOS ISLANDS
TD CHAD
TF FRENCH SOUTHERN TERRITORIES
TG TOGO
TH THAILAND
TJ TAJIKISTAN
TK TOKELAU
TM TURKMENISTAN
TN TUNISIA
TO TONGA
TP TIMOR LESTE
TR TURKEY
TT TRINIDAD AND TOBAGO
TV TUVALU
TW TAIWAN
TZ TANZANIA
UA UKRAINE
UG UGANDA
UM UNITED STATES MINOR OUTLYING ISLANDS
US UNITED STATES
UY URUGUAY
UZ UZBEKISTAN
VA HOLY SEE (VATICAN CITY STATE)
VC SAINT VINCENT AND THE GRENADINES
VE VENEZUELA
VG VIRGIN ISLANDS BRITISH
VI VIRGIN ISLANDS U.S
VN VIETNAM
VU VANUATU
WF WALLIS AND FUTUNA
YE YEMEN
YT MAYOTTE
YU YUGOSLAVIA
ZA SOUTH AFRICA
ZM ZAMBIA
ZW ZIMBABWE