Crew's Effects

Passenger list

Crew's Money

Ship's Stores
Last update

Declaration
COUNTRY

Crew List

NIL List
Pre-Arr

Decl.

Decl.
PORT

Pre-Arr form, crew list,

YOKOHAMA JAPAN Nov-08 narcotics, port list
3 Local Nil 1 Nil 1 Local 1

NAGOYA JAPAN Nov-08 Pre-Arr form 5 Local Nil Nil Nil 1 Local 1

Pre-Arr form (ISPS, Health,

Complementary), crew list,
CALLAO PERU Dec-08 port list, vacc. list, passeng. 4 4 2 Nil 2 6
list

IQUIQUE CHILE Dec-08 Nil 6 Nil 4 Nil 4 3

SAN
CHILE Dec-08
ANTONIO
 Vaccination List

Ship's Currency
Maritime Health

Port of Call List

PARTICULARS
Narcotics List

SHOREPASS
Declaration
Declaration
General

SHIP'S
Decl.
PERSONS BOARDING
(Incl. Agent)

Pre-arr
Nil Nil 1 Local 3 Nil Yes Nil Agent, Quarantine
only

Nil Nil 1 Local 4 1 Nil Yes Nil Agent

Agent, Quarantine,
4 1 Pre-Arr 2 2 Nil Yes Nil
Customs, Immigration

Nil 1 1 5 Nil Nil Yes Nil

REMARKS
 Basic data for all lists automatically fills up
Owner:
Name of ship: M/V "ANDINO" Official No.: 91587 Copmany:
Nationality: GERMAN Port of Registry: HAMBURG Charterer:
GRT: 40,628 Voyage No.: 3 Master:
NTT: 14163 Number of Crew: 22
Arrival Port / Country: YOKOHAMA JAPAN Planned stay in port:
X Arrival Arrival Date / Time: 27-01-2009 1
Departure Departure Date / Time: 29-01-2009
(select with "x") Last Port / Country: SAN ANTONIO CHILE
Arrival Date / Time: 26-12-2008 0900
Today: Departure Date / Time: 26-12-2008
23-Mar-2022 Next Port / Country: NAGOYA JAPAN
Arrival Date / Time: 30-01-2009
CREW ON ARRIVAL:

No. FAMILY NAME GIVEN NAME(S) MIDDLE NAME RANK BIRTH DATE

1 CHWIEDUK ANDRZEJ MASTER 30/Nov/1957

2 STOLYAROV VADYM C/OFF 24/Mar/1976
3 ROBLES ROSAURO MEDINA 2/OFF 04/Jun/1970
4 BEDNAREK MALGORZATA ANNA 3/OFF 16/Oct/1982
5 DOBRZANSKI ROMAN BOGDAN C/ENG 02/Jun/1957
6 FLOROI FLORIN CONSTANTIN 2/ENG 11/Apr/1971
7 ANDRASZEWICZ DARIUSZ SEBASTIAN 3/ENG 10/Sep/1981
8 PRZYBYLSKI ROMAN WOJCIECH ELEC 25/Sep/1954
9 CASTILLO ROMEO ATIENZA BOSUN 04/Dec/1963
10 PADILLO JOVENSON SALAR A/B 31/Dec/1975
11 JACA MANOLO JR DIMAFELIX A/B 03/Apr/1972
12 CASTRO DANIEL DE LEON A/B 23/Nov/1961
13 TY DANIEL JR. LAO O/S 27/Jul/1974
14 BACOL FELIZARDO ESGUERRA O/S 17/Sep/1982
15 ABEDEJOS LYMIN BATAN FITTER 11/Jan/1966
16 CRISTOBAL CRISTOPHER FERRER OILER 17/Sep/1975
17 RAMIREZ REYNALD ELICOT OILER 27/Jul/1967
18 CASTILLA RYAN PATRICK GAONA WIPER 29/Sep/1981
19 SAYSON JOSEPH VALCORZA C/COOK 31/Jan/1970
20 DRAPER EDUARDO QUIRAO MESSMAN 27/Aug/1968
21 TAGOD BILLY SALVO D/CDT 11/Apr/1983
22 GALORIO OMEGA ANDREW SABIDO E/CDT 22/Oct/1984
23
24
25
26
27
28
PASSENGERS ON ARRIVAL:
1
2
3
4
5
6
7
8
9
10
CREW ON DEPARTURE:
1 IGNATOWICZ RYSZARD MASTER 03/Jul/1949
2 STOLYAROV VADYM C/OFF 24/Mar/1976
3 ROBLES ROSAURO MEDINA 2/OFF 04/Jun/1970
4 BEDNAREK MALGORZATA ANNA 3/OFF 16/Oct/1982
5 DOBRZANSKI ROMAN BOGDAN C/ENG 02/Jun/1957
6 FLOROI FLORIN CONSTANTIN 2/ENG 11/Apr/1971
7 ANDRASZEWICZ DARIUSZ SEBASTIAN 3/ENG 10/Sep/1981
8 PRZYBYLSKI ROMAN WOJCIECH ELEC 25/Sep/1954
9 CASTILLO ROMEO ATIENZA BOSUN 04/Dec/1963
10 PADILLO JOVENSON SALAR A/B 31/Dec/1975
11 JACA MANOLO JR DIMAFELIX A/B 03/Apr/1972
12 CASTRO DANIEL DE LEON A/B 23/Nov/1961
13 TY DANIEL JR. LAO O/S 27/Jul/1974
14 BACOL FELIZARDO ESGUERRA O/S 17/Sep/1982
15 ABEDEJOS LYMIN BATAN FITTER 11/Jan/1966
16 CRISTOBAL CRISTOPHER FERRER OILER 17/Sep/1975
17 RAMIREZ REYNALD ELICOT OILER 27/Jul/1967
18 CASTILLA RYAN PATRICK GAONA WIPER 29/Sep/1981
19 SAYSON JOSEPH VALCORZA C/COOK 31/Jan/1970
20 DRAPER EDUARDO QUIRAO MESSMAN 27/Aug/1968
21 TAGOD BILLY SALVO D/CDT 11/Apr/1983
22 GALORIO OMEGA ANDREW SABIDO E/CDT 22/Oct/1984
23
24
25
26
27
28
PASSENGERS ON DEPARTURE:
1
2
3
4
5
6
7
8
9
10
 MS "MONZA" Shifffahrtsgesellschaft mbH & Co.KG, Hamburg, Germany
NSC Schifffahrtsgesellschaft mbH & Cie.KG, Hamburg, Germany
CCNI - Compania Chilena de Navegacion Interoceanica
ANDRZEJ CHWIEDUK

Planned stay in port:

Day

SIGN ON
BIRTH PLACE NATIONALITY SEX SIGN ON DATE SIGN ON PORT
COUNTRY
PYSKOWICE POLISH Male 12/Oct/2008 Callao Peru
UKRAINE UKRAINIAN Male 12/Oct/2008 Callao Peru
MANILA FILIPINO Male 19/Jun/2008 Rijeka Croatia
WROCLAW POLISH Female 18/Oct/2008 San Antonio Chile
PRABUTY POLISH Male 12/Oct/2008 Callao Peru
BRASOV ROMANIAN Male 18/Oct/2008 San Antonio Chile
SZCZECIN POLISH Male 12/Oct/2008 Callao Peru
GDYNIA POLISH Male 18/Oct/2008 San Antonio Chile
VICTORIA, ORIENT FILIPINO Male 19/Jun/2008 Rijeka Croatia
MATALOM, LEYTE FILIPINO Male 19/Jun/2008 Rijeka Croatia
NASUGBU, BATANGFILIPINO Male 19/Jun/2008 Rijeka Croatia
MANILA FILIPINO Male 18/Oct/2008 San Antonio Chile
SAN FRANCISCO, S FILIPINO Male 19/Jun/2008 Rijeka Croatia
BUTUAN CITY FILIPINO Male 19/Jun/2008 Rijeka Croatia
PASIG, RIZAL FILIPINO Male 19/Jun/2008 Rijeka Croatia
ILOILO CITY FILIPINO Male 19/Jun/2008 Rijeka Croatia
TAGBILARAN CITY FILIPINO Male 19/Jun/2008 Rijeka Croatia
MANILA FILIPINO Male 19/Jun/2008 Rijeka Croatia
MINGLANILLA, CEB FILIPINO Male 19/Jun/2008 Rijeka Croatia
QUEZON CITY FILIPINO Male 19/Jun/2008 Rijeka Croatia
PASIG, METRO MANFILIPINO Male 19/Jun/2008 Rijeka Croatia
LANAO DEL NORTE FILIPINO Male 19/Jun/2008 Rijeka Croatia
WLOKI POLISH Male 28/Jan/2009 Yokohama Japan
UKRAINE UKRAINIAN Male 12/Oct/2008 Callao Peru
MANILA FILIPINO Male 19/Jun/2008 Rijeka Croatia
WROCLAW POLISH Female 18/Oct/2008 San Antonio Chile
PRABUTY POLISH Male 12/Oct/2008 Callao Peru
BRASOV ROMANIAN Male 18/Oct/2008 San Antonio Chile
SZCZECIN POLISH Male 12/Oct/2008 Callao Peru
GDYNIA POLISH Male 18/Oct/2008 San Antonio Chile
VICTORIA, ORIENT FILIPINO Male 19/Jun/2008 Rijeka Croatia
MATALOM, LEYTE FILIPINO Male 19/Jun/2008 Rijeka Croatia
NASUGBU, BATANGFILIPINO Male 19/Jun/2008 Rijeka Croatia
MANILA FILIPINO Male 18/Oct/2008 San Antonio Chile
SAN FRANCISCO, S FILIPINO Male 19/Jun/2008 Rijeka Croatia
BUTUAN CITY FILIPINO Male 19/Jun/2008 Rijeka Croatia
PASIG, RIZAL FILIPINO Male 19/Jun/2008 Rijeka Croatia
ILOILO CITY FILIPINO Male 19/Jun/2008 Rijeka Croatia
TAGBILARAN CITY FILIPINO Male 19/Jun/2008 Rijeka Croatia
MANILA FILIPINO Male 19/Jun/2008 Rijeka Croatia
MINGLANILLA, CEB FILIPINO Male 19/Jun/2008 Rijeka Croatia
QUEZON CITY FILIPINO Male 19/Jun/2008 Rijeka Croatia
PASIG, METRO MANFILIPINO Male 19/Jun/2008 Rijeka Croatia
LANAO DEL NORTE FILIPINO Male 19/Jun/2008 Rijeka Croatia
 PASSPORT ISSUE PASSPORT
PASSPORT NO NATIONAL SB NO SB ISSUE PLACE
PLACE EXPIRY
AF0853632 Wojewoda Slaski 29/Jan/2013 0241301 Gdynia
AH832082 Ukraine 09/Jul/2011 AB328382 Ukraine
XX1025611 Poea, Manila 23/Apr/2013 B0149247 Manila
AS9059366 Wojewoda Dolnoslask 02/Oct/2016 0234497 Szczecin
BM4789059 Wojewoda Pomorski 28/Oct/2009 0184782 Gdynia
09767138 Brasov 18/Feb/2010 0005978 Constanta
AD7064101 Wojewoda zachodnio 11/Mar/2012 0234825 Szczecin
BM5524822 Wojewoda Pomorski 16/Mar/2010 0154087 Gdynia
QQ0694262 Lucena City 27/Jul/2010 B245882 Manila
QQ0111404 Manila 18/Apr/2010 B057082 Manila
TT0730757 Manila 17/Aug/2011 B0334206 Manila
PP0756483 Manila 03/Feb/2010 B119474 Manila
UU0060419 Manila 19/Oct/2011 B0321983 Manila
SS0861620 Manila 30/Mar/2011 A783192 Manila
PP0640172 Manila 24/Jan/2010 B301551 Manila
PP0946630 Manila 03/Mar/2010 B220084 Manila
QQ0766183 Manila 22/Jul/2010 B0559516 Manila
SS0766517 Manila 30/Mar/2011 A949733 Manila
QQ0252143 Manila 21/Apr/2010 B217936 Manila
RR0289836 Manila 27/Oct/2010 B0162700 Manila
VV0832830 Cebu City 21/Nov/2012 B0527499 Manila
XX0984703 Cebu 18/Apr/2013 B0536516 Cebu
AS4164429 Wloki 20/Nov/2016 0155187
AH832082 Ukraine 09/Jul/2011 AB328382 Ukraine
XX1025611 Poea, Manila 23/Apr/2013 B0149247 Manila
AS9059366 Wojewoda Dolnoslask 02/Oct/2016 0234497 Szczecin
BM4789059 Wojewoda Pomorski 28/Oct/2009 0184782 Gdynia
09767138 Brasov 18/Feb/2010 0005978 Constanta
AD7064101 Wojewoda zachodnio 11/Mar/2012 0234825 Szczecin
BM5524822 Wojewoda Pomorski 16/Mar/2010 0154087 Gdynia
QQ0694262 Lucena City 27/Jul/2010 B245882 Manila
QQ0111404 Manila 18/Apr/2010 B057082 Manila
TT0730757 Manila 17/Aug/2011 B0334206 Manila
PP0756483 Manila 03/Feb/2010 B119474 Manila
UU0060419 Manila 19/Oct/2011 B0321983 Manila
SS0861620 Manila 30/Mar/2011 A783192 Manila
PP0640172 Manila 24/Jan/2010 B301551 Manila
PP0946630 Manila 03/Mar/2010 B220084 Manila
QQ0766183 Manila 22/Jul/2010 B0559516 Manila
SS0766517 Manila 30/Mar/2011 A949733 Manila
QQ0252143 Manila 21/Apr/2010 B217936 Manila
RR0289836 Manila 27/Oct/2010 B0162700 Manila
VV0832830 Cebu City 21/Nov/2012 B0527499 Manila
XX0984703 Cebu 18/Apr/2013 B0536516 Cebu
 YELLOW FEVER
SB EXPIRY FLAG SB NO SB ISSUE PLACE SB EXPIRY
VACC. DATE
Unlimited 02/Jul/2005
13/Dec/2010 30/May/2001
14/Mar/2011 10/Oct/2003
Unlimited 24/Oct/2006
Unlimited 19/Sep/2006
06/Oct/2010 22/Sep/2008
Unlimited 03/Feb/2004
Unlimited 10/Aug/1999
13/Jul/2010 11/Jan/2002
05/Jul/2009 05/Jan/2001
26/Dec/2011 31/Mar/1999
10/Feb/2010 10/Jan/2003
05/Nov/2011 06/Feb/2007
14/Mar/2009 08/May/2006
27/Dec/2010 22/Jun/2007
04/May/2010 28/Jul/2006
21/May/2013 17/Jan/2003
29/Mar/2009 31/Mar/2006
19/Apr/2010 07/May/2008
07/May/2011 25/Sep/2006
22/Jan/2013 14/Feb/2008
02/Apr/2013 27/May/2008
Unlimited
13/Dec/2010 30/May/2001
14/Mar/2011 10/Oct/2003
Unlimited 24/Oct/2006
Unlimited 19/Sep/2006
06/Oct/2010 22/Sep/2008
Unlimited 03/Feb/2004
Unlimited 10/Aug/1999
13/Jul/2010 11/Jan/2002
05/Jul/2009 05/Jan/2001
26/Dec/2011 31/Mar/1999
10/Feb/2010 10/Jan/2003
05/Nov/2011 06/Feb/2007
14/Mar/2009 08/May/2006
27/Dec/2010 22/Jun/2007
04/May/2010 28/Jul/2006
21/May/2013 17/Jan/2003
29/Mar/2009 31/Mar/2006
19/Apr/2010 07/May/2008
07/May/2011 25/Sep/2006
22/Jan/2013 14/Feb/2008
02/Apr/2013 27/May/2008
TYPHOID VACC. HEPATITEI VACC. GERMAN VISA
US VISA EXPIRY GERMAN VISA No.
DATE DATE EXPIRY
08/Sep/2008 08/Sep/2008 29/Oct/2016
15/Mar/2009 D36366843
23/May/2008 23/May/2008 22/Jan/2009 18/Mar/2009 D35813708
11/Sep/2008 11/Sep/2008 18/Oct/2016
06/Mar/2008 13/Apr/2003 27/Jan/2012
18/Sep/2008 17/Sep/2008 20/Jul/2010
16/Sep/2008 16/Sep/2008
01/Dec/2006 01/Dec/2006 18/Jun/2012
23/Oct/2007 23/May/2008 31/May/2009 D35813713
21/May/2008 21/May/2008 20/Sep/2012 31/May/2009 D35813709
11/Apr/2008 11/Apr/2008 16/Apr/2013 31/May/2009 D35813718
06/Oct/2008 06/Oct/2008 17/Mar/2010 14/Jul/2009 D35813721
20/May/2008 20/May/2008 14/Dec/2011 31/May/2009 D35813720
02/May/2008 02/May/2008 31/Mar/2013 31/May/2009 D35813710
08/May/2008 08/May/2008 14/Feb/2011 31/May/2009 D35813719
14/Apr/2005 14/Apr/2005 12/Feb/2009 31/May/2009 D35813712
19/May/2008 19/May/2008 28/Aug/2010 31/May/2009 D35813714
16/Apr/2008 16/Apr/2008 25/Apr/2012 31/May/2009 D35813700
04/Jun/2008 04/Jun/2008 25/Mar/2012 31/May/2009 D35813716
21/Apr/2008 21/Apr/2008 02/Mar/2013 31/May/2009 D35813711
02/May/2008 02/May/2008 22/Apr/2013 31/May/2009 D35813717
28/Apr/2008 28/Apr/2008 01/Jun/2013 31/May/2009 D35813715
 15/Mar/2009 D36366843
23/May/2008 23/May/2008 22/Jan/2009 18/Mar/2009 D35813708
11/Sep/2008 11/Sep/2008 18/Oct/2016
06/Mar/2008 13/Apr/2003 27/Jan/2012
18/Sep/2008 17/Sep/2008 20/Jul/2010
16/Sep/2008 16/Sep/2008
01/Dec/2006 01/Dec/2006 18/Jun/2012
23/Oct/2007 23/May/2008 31/May/2009 D35813713
21/May/2008 21/May/2008 20/Sep/2012 31/May/2009 D35813709
11/Apr/2008 11/Apr/2008 16/Apr/2013 31/May/2009 D35813718
06/Oct/2008 06/Oct/2008 17/Mar/2010 14/Jul/2009 D35813721
20/May/2008 20/May/2008 14/Dec/2011 31/May/2009 D35813720
02/May/2008 02/May/2008 31/Mar/2013 31/May/2009 D35813710
08/May/2008 08/May/2008 14/Feb/2011 31/May/2009 D35813719
14/Apr/2005 14/Apr/2005 12/Feb/2009 31/May/2009 D35813712
19/May/2008 19/May/2008 28/Aug/2010 31/May/2009 D35813714
16/Apr/2008 16/Apr/2008 25/Apr/2012 31/May/2009 D35813700
04/Jun/2008 04/Jun/2008 25/Mar/2012 31/May/2009 D35813716
21/Apr/2008 21/Apr/2008 02/Mar/2013 31/May/2009 D35813711
02/May/2008 02/May/2008 22/Apr/2013 31/May/2009 D35813717
28/Apr/2008 28/Apr/2008 01/Jun/2013 31/May/2009 D35813715
 CREW LIST
( Name of shipping line, agent, etc.)

NSC Schifffahrtsgesellschaft mbH & Cie. KG ✘ Arrival Departure Page No 1

1. Name of the ship 2. Port of Arrival / Departure: 3. Date of arrival:

M/V "ANDINO" YOKOHAMA, JAPAN 27-01-2009
4. Nationality of ship: 5. Port arrived from: 6. Nature / No. of
GERMAN SAN ANTONIO, CHILE Identity Document
7. 8. Family name, given names 9. Rank 10. 11. Date / place of birth 12. Date / place of Passport
Nationality joining
No or rating Number Expiry date
Callao,
1 CHWIEDUK, ANDRZEJ MASTER POLISH 30-Nov-1957 PYSKOWICE 12-Oct-2008
Peru
AF0853632 29-Jan-2013

Callao,
2 STOLYAROV, VADYM C/OFF UKRAINIAN 24-Mar-1976 UKRAINE 12-Oct-2008
Peru
AH832082 09-Jul-2011
Rijeka,
3 ROBLES, ROSAURO MEDINA 2/OFF FILIPINO 04-Jun-1970 MANILA 19-Jun-2008
Croatia
XX1025611 23-Apr-2013
San
4 BEDNAREK, MALGORZATA ANNA 3/OFF POLISH 16-Oct-1982 WROCLAW 18-Oct-2008 Antonio, AS9059366 02-Oct-2016
Chile
Callao,
5 DOBRZANSKI, ROMAN BOGDAN C/ENG POLISH 02-Jun-1957 PRABUTY 12-Oct-2008
Peru
BM4789059 28-Oct-2009
San
6 FLOROI, FLORIN CONSTANTIN 2/ENG ROMANIAN 11-Apr-1971 BRASOV 18-Oct-2008 Antonio, 09767138 18-Feb-2010
Chile
Callao,
7 ANDRASZEWICZ, DARIUSZ SEBASTIAN 3/ENG POLISH 10-Sep-1981 SZCZECIN 12-Oct-2008
Peru
AD7064101 11-Mar-2012
San
8 PRZYBYLSKI, ROMAN WOJCIECH ELEC POLISH 25-Sep-1954 GDYNIA 18-Oct-2008 Antonio, BM5524822 16-Mar-2010
VICTORIA, Chile
Rijeka,
9 CASTILLO, ROMEO ATIENZA BOSUN FILIPINO 04-Dec-1963 ORIENTAL 19-Jun-2008
Croatia
QQ0694262 27-Jul-2010
MINDORO
Rijeka,
IMO Convention on Facilitation of International

10 PADILLO, JOVENSON SALAR A/B FILIPINO 31-Dec-1975 MATALOM, LEYTE 19-Jun-2008 QQ0111404 18-Apr-2010
Maritime Traffic

Croatia
NASUGBU, Rijeka,
11 JACA, MANOLO JR DIMAFELIX A/B FILIPINO 03-Apr-1972
BATANGAS
19-Jun-2008
Croatia
TT0730757 17-Aug-2011
San
12 CASTRO, DANIEL DE LEON A/B FILIPINO 23-Nov-1961 MANILA 18-Oct-2008 Antonio, PP0756483 03-Feb-2010
Chile
SAN FRANCISCO, Rijeka,
13 TY, DANIEL JR. LAO O/S FILIPINO 27-Jul-1974
SOUTHERN LEYTE
19-Jun-2008
Croatia
UU0060419 19-Oct-2011

Rijeka,
14 BACOL, FELIZARDO ESGUERRA O/S FILIPINO 17-Sep-1982 BUTUAN CITY 19-Jun-2008
Croatia
SS0861620 30-Mar-2011

Rijeka,
15 ABEDEJOS, LYMIN BATAN FITTER FILIPINO 11-Jan-1966 PASIG, RIZAL 19-Jun-2008
Croatia
PP0640172 24-Jan-2010

Rijeka,
16 CRISTOBAL, CRISTOPHER FERRER OILER FILIPINO 17-Sep-1975 ILOILO CITY 19-Jun-2008
Croatia
PP0946630 03-Mar-2010

Rijeka,
17 RAMIREZ, REYNALD ELICOT OILER FILIPINO 27-Jul-1967 TAGBILARAN CITY 19-Jun-2008
Croatia
QQ0766183 22-Jul-2010

Rijeka,
18 CASTILLA, RYAN PATRICK GAONA WIPER FILIPINO 29-Sep-1981 MANILA 19-Jun-2008
Croatia
SS0766517 30-Mar-2011

MINGLANILLA, Rijeka,
19 SAYSON, JOSEPH VALCORZA C/COOK FILIPINO 31-Jan-1970
CEBU
19-Jun-2008
Croatia
QQ0252143 21-Apr-2010

Rijeka,
20 DRAPER, EDUARDO QUIRAO MESSMAN FILIPINO 27-Aug-1968 QUEZON CITY 19-Jun-2008
Croatia
RR0289836 27-Oct-2010

PASIG, METRO Rijeka,

21 TAGOD, BILLY SALVO D/CDT FILIPINO 11-Apr-1983
MANILA
19-Jun-2008
Croatia
VV0832830 21-Nov-2012

Rijeka,
22 GALORIO, OMEGA ANDREW SABIDO E/CDT FILIPINO 22-Oct-1984 LANAO DEL NORTE 19-Jun-2008
Croatia
XX0984703 18-Apr-2013

IMO FAL
Form 5

12. Date and sign by the master, authorized agent or officer

C97 Capt. ANDRZEJ CHWIEDUK
Master
27-01-2009
 CREW LIST
( Name of shipping line, agent, etc.)

NSC Schifffahrtsgesellschaft mbH & Cie. KG Arrival ✘ Departure Page No 1

1. Name of the ship 2. Port of Arrival / Departure: 3. Date of departure:

M/V "ANDINO" YOKOHAMA, JAPAN 29-01-2009
4. Nationality of ship: 5. Port arrived from: 6. Nature / No. of
GERMAN SAN ANTONIO, CHILE Identity Document
7. 8. Family name, given names 9. Rank 10. 11. Date / place of birth 12. Date / place of Passport
Nationality joining
No or rating Number Expiry date
Yokohama,
1 IGNATOWICZ, RYSZARD MASTER POLISH 03-Jul-1949 WLOKI 28-Jan-2009
Japan
AS4164429 20-Nov-2016

Callao,
2 STOLYAROV, VADYM C/OFF UKRAINIAN 24-Mar-1976 UKRAINE 12-Oct-2008
Peru
AH832082 09-Jul-2011
Rijeka,
3 ROBLES, ROSAURO MEDINA 2/OFF FILIPINO 04-Jun-1970 MANILA 19-Jun-2008
Croatia
XX1025611 23-Apr-2013
San
4 BEDNAREK, MALGORZATA ANNA 3/OFF POLISH 16-Oct-1982 WROCLAW 18-Oct-2008 Antonio, AS9059366 02-Oct-2016
Chile
Callao,
5 DOBRZANSKI, ROMAN BOGDAN C/ENG POLISH 02-Jun-1957 PRABUTY 12-Oct-2008
Peru
BM4789059 28-Oct-2009
San
6 FLOROI, FLORIN CONSTANTIN 2/ENG ROMANIAN 11-Apr-1971 BRASOV 18-Oct-2008 Antonio, 09767138 18-Feb-2010
Chile
Callao,
7 ANDRASZEWICZ, DARIUSZ SEBASTIAN
3/ENG POLISH 10-Sep-1981 SZCZECIN 12-Oct-2008
Peru
AD7064101 11-Mar-2012
San
8 PRZYBYLSKI, ROMAN WOJCIECH
ELEC POLISH 25-Sep-1954 GDYNIA 18-Oct-2008 Antonio, BM5524822 16-Mar-2010
VICTORIA, Chile
Rijeka,
9 CASTILLO, ROMEO ATIENZA BOSUN FILIPINO 04-Dec-1963 ORIENTAL 19-Jun-2008
Croatia
QQ0694262 27-Jul-2010
MINDORO
IMO Convention on Facilitation of International

Rijeka,
10
Maritime Traffic

PADILLO, JOVENSON SALAR A/B FILIPINO 31-Dec-1975 MATALOM, LEYTE 19-Jun-2008 QQ0111404 18-Apr-2010
Croatia
NASUGBU, Rijeka,
11 JACA, MANOLO JR DIMAFELIX A/B FILIPINO 03-Apr-1972
BATANGAS
19-Jun-2008
Croatia
TT0730757 17-Aug-2011
San
12 CASTRO, DANIEL DE LEON A/B FILIPINO 23-Nov-1961 MANILA 18-Oct-2008 Antonio, PP0756483 03-Feb-2010
Chile
SAN FRANCISCO, Rijeka,
13 TY, DANIEL JR. LAO O/S FILIPINO 27-Jul-1974
SOUTHERN LEYTE
19-Jun-2008
Croatia
UU0060419 19-Oct-2011

Rijeka,
14 BACOL, FELIZARDO ESGUERRA O/S FILIPINO 17-Sep-1982 BUTUAN CITY 19-Jun-2008
Croatia
SS0861620 30-Mar-2011

Rijeka,
15 ABEDEJOS, LYMIN BATAN FITTER FILIPINO 11-Jan-1966 PASIG, RIZAL 19-Jun-2008
Croatia
PP0640172 24-Jan-2010

Rijeka,
16 CRISTOBAL, CRISTOPHER FERRER
OILER FILIPINO 17-Sep-1975 ILOILO CITY 19-Jun-2008
Croatia
PP0946630 03-Mar-2010

Rijeka,
17 RAMIREZ, REYNALD ELICOT OILER FILIPINO 27-Jul-1967 TAGBILARAN CITY 19-Jun-2008
Croatia
QQ0766183 22-Jul-2010

Rijeka,
18 CASTILLA, RYAN PATRICK GAONA WIPER FILIPINO 29-Sep-1981 MANILA 19-Jun-2008
Croatia
SS0766517 30-Mar-2011

MINGLANILLA, Rijeka,
19 SAYSON, JOSEPH VALCORZA C/COOK FILIPINO 31-Jan-1970
CEBU
19-Jun-2008
Croatia
QQ0252143 21-Apr-2010

Rijeka,
20 DRAPER, EDUARDO QUIRAO MESSMAN FILIPINO 27-Aug-1968 QUEZON CITY 19-Jun-2008
Croatia
RR0289836 27-Oct-2010

PASIG, METRO Rijeka,

21 TAGOD, BILLY SALVO D/CDT FILIPINO 11-Apr-1983
MANILA
19-Jun-2008
Croatia
VV0832830 21-Nov-2012

Rijeka,
22 GALORIO, OMEGA ANDREW SABIDO
E/CDT FILIPINO 22-Oct-1984 LANAO DEL NORTE 19-Jun-2008
Croatia
XX0984703 18-Apr-2013

23

IMO FAL
Form 5

12. Date and sign by the master, authorized agent or officer

C97 Capt. RYSZARD IGNATOWICZ
Master
29-01-2009
 CREW LIST
( Name of shipping line, agent, etc.)

NSC Schifffahrtsgesellschaft mbH & Cie. KG ✘ Arrival Departure Page No 1

1. Name of the ship 2. Port of Arrival / Departure: 3. Date of arrival:

M/V "ANDINO" YOKOHAMA, JAPAN 27-01-2009
4. Nationality of ship: 5. Port arrived from: 6. Nature / No. of
GERMAN SAN ANTONIO, CHILE Identity Document
7. 8. Family name, given names 9. Rank 10. 11. Date / place of birth 12. Date / place of Seaman's Book
Nationality joining
No or rating Number Expiry date
Callao,
1 CHWIEDUK, ANDRZEJ MASTER POLISH 30-Nov-1957 PYSKOWICE 12-Oct-2008
Peru 0241301 Unlimited
Callao,
2 STOLYAROV, VADYM C/OFF UKRAINIAN 24-Mar-1976 UKRAINE 12-Oct-2008
Peru AB328382 13-Dec-10
Rijeka,
3 ROBLES, ROSAURO MEDINA 2/OFF FILIPINO 04-Jun-1970 MANILA 19-Jun-2008
Croatia B0149247 14-Mar-11
San
4 BEDNAREK, MALGORZATA ANNA 3/OFF POLISH 16-Oct-1982 WROCLAW 18-Oct-2008 Antonio,
0234497 Unlimited
Chile
Callao,
5 DOBRZANSKI, ROMAN BOGDAN C/ENG POLISH 02-Jun-1957 PRABUTY 12-Oct-2008
Peru 0184782 Unlimited
San
6 FLOROI, FLORIN CONSTANTIN 2/ENG ROMANIAN 11-Apr-1971 BRASOV 18-Oct-2008 Antonio,
0005978 6-Oct-10
Chile
Callao,
7 ANDRASZEWICZ, DARIUSZ SEBASTIAN 3/ENG POLISH 10-Sep-1981 SZCZECIN 12-Oct-2008
Peru 0234825 Unlimited
San
8 PRZYBYLSKI, ROMAN WOJCIECH ELEC POLISH 25-Sep-1954 GDYNIA 18-Oct-2008 Antonio,
0154087 Unlimited
VICTORIA, Chile
Rijeka,
9 CASTILLO, ROMEO ATIENZA BOSUN FILIPINO 04-Dec-1963 ORIENTAL 19-Jun-2008
Croatia B245882 13-Jul-10
MINDORO
Rijeka,
10 PADILLO, JOVENSON SALAR A/B FILIPINO 31-Dec-1975 MATALOM, LEYTE 19-Jun-2008
Croatia B057082 5-Jul-09
IMO Convention on Facilitation of International

NASUGBU, Rijeka,
Maritime Traffic

11 JACA, MANOLO JR DIMAFELIX A/B FILIPINO 03-Apr-1972

BATANGAS
19-Jun-2008
Croatia B0334206 26-Dec-11
San
12 CASTRO, DANIEL DE LEON A/B FILIPINO 23-Nov-1961 MANILA 18-Oct-2008 Antonio,
B119474 10-Feb-10
Chile
SAN FRANCISCO, Rijeka,
13 TY, DANIEL JR. LAO O/S FILIPINO 27-Jul-1974
SOUTHERN LEYTE
19-Jun-2008
Croatia B0321983 5-Nov-11
Rijeka,
14 BACOL, FELIZARDO ESGUERRA O/S FILIPINO 17-Sep-1982 BUTUAN CITY 19-Jun-2008
Croatia A783192 14-Mar-09
Rijeka,
15 ABEDEJOS, LYMIN BATAN FITTER FILIPINO 11-Jan-1966 PASIG, RIZAL 19-Jun-2008
Croatia B301551 27-Dec-10
Rijeka,
16 CRISTOBAL, CRISTOPHER FERRER OILER FILIPINO 17-Sep-1975 ILOILO CITY 19-Jun-2008
Croatia B220084 4-May-10
Rijeka,
17 RAMIREZ, REYNALD ELICOT OILER FILIPINO 27-Jul-1967 TAGBILARAN CITY 19-Jun-2008
Croatia B0559516 21-May-13
Rijeka,
18 CASTILLA, RYAN PATRICK GAONA WIPER FILIPINO 29-Sep-1981 MANILA 19-Jun-2008
Croatia A949733 29-Mar-09
MINGLANILLA, Rijeka,
19 SAYSON, JOSEPH VALCORZA C/COOK FILIPINO 31-Jan-1970
CEBU
19-Jun-2008
Croatia B217936 19-Apr-10
Rijeka,
20 DRAPER, EDUARDO QUIRAO MESSMAN FILIPINO 27-Aug-1968 QUEZON CITY 19-Jun-2008
Croatia B0162700 7-May-11
PASIG, METRO Rijeka,
21 TAGOD, BILLY SALVO D/CDT FILIPINO 11-Apr-1983
MANILA
19-Jun-2008
Croatia B0527499 22-Jan-13
Rijeka,
22 GALORIO, OMEGA ANDREW SABIDO E/CDT FILIPINO 22-Oct-1984 LANAO DEL NORTE 19-Jun-2008
Croatia B0536516 2-Apr-13

IMO FAL
Form 5

12. Date and sign by the master, authorized agent or officer

C97 Capt. ANDRZEJ CHWIEDUK
Master
27-01-2009
 CREW LIST
( Name of shipping line, agent, etc.)

NSC Schifffahrtsgesellschaft mbH & Cie. KG ✘ Arrival Departure Page No 1

1. Name of the ship 2. Port of Arrival / Departure: 3. Date of departure:

M/V "ANDINO" YOKOHAMA, JAPAN 29-01-2009
4. Nationality of ship: 5. Port arrived from: 6. Nature / No. of
GERMAN SAN ANTONIO, CHILE Identity Document
7. 8. Family name, given names 9. Rank 10. 11. Date / place of birth 12. Date / place of Seaman's Book
Nationality joining
No or rating Number Expiry date
Yokohama,
1 IGNATOWICZ, RYSZARD MASTER POLISH 03-Jul-1949 WLOKI 28-Jan-2009
Japan 0155187 Unlimited
Callao,
2 STOLYAROV, VADYM C/OFF UKRAINIAN 24-Mar-1976 UKRAINE 12-Oct-2008
Peru AB328382 13-Dec-2010
Rijeka,
3 ROBLES, ROSAURO MEDINA 2/OFF FILIPINO 04-Jun-1970 MANILA 19-Jun-2008
Croatia B0149247 14-Mar-2011
San
4 BEDNAREK, MALGORZATA ANNA 3/OFF POLISH 16-Oct-1982 WROCLAW 18-Oct-2008 Antonio,
0234497 Unlimited
Chile
Callao,
5 DOBRZANSKI, ROMAN BOGDAN C/ENG POLISH 02-Jun-1957 PRABUTY 12-Oct-2008
Peru 0184782 Unlimited
San
6 FLOROI, FLORIN CONSTANTIN 2/ENG ROMANIAN 11-Apr-1971 BRASOV 18-Oct-2008 Antonio,
0005978 06-Oct-2010
Chile
Callao,
7 ANDRASZEWICZ, DARIUSZ SEBASTIAN
3/ENG POLISH 10-Sep-1981 SZCZECIN 12-Oct-2008
Peru 0234825 Unlimited
San
8 PRZYBYLSKI, ROMAN WOJCIECH
ELEC POLISH 25-Sep-1954 GDYNIA 18-Oct-2008 Antonio,
0154087 Unlimited
VICTORIA, Chile
Rijeka,
9 CASTILLO, ROMEO ATIENZA BOSUN FILIPINO 04-Dec-1963 ORIENTAL 19-Jun-2008
Croatia B245882 13-Jul-2010
MINDORO
Rijeka,
10 PADILLO, JOVENSON SALAR A/B FILIPINO 31-Dec-1975 MATALOM, LEYTE 19-Jun-2008
Croatia B057082 05-Jul-2009
IMO Convention on Facilitation of International

NASUGBU, Rijeka,
Maritime Traffic

11 JACA, MANOLO JR DIMAFELIX A/B FILIPINO 03-Apr-1972

BATANGAS
19-Jun-2008
Croatia B0334206 26-Dec-2011
San
12 CASTRO, DANIEL DE LEON A/B FILIPINO 23-Nov-1961 MANILA 18-Oct-2008 Antonio,
B119474 10-Feb-2010
Chile
SAN FRANCISCO, Rijeka,
13 TY, DANIEL JR. LAO O/S FILIPINO 27-Jul-1974
SOUTHERN LEYTE
19-Jun-2008
Croatia B0321983 05-Nov-2011
Rijeka,
14 BACOL, FELIZARDO ESGUERRA O/S FILIPINO 17-Sep-1982 BUTUAN CITY 19-Jun-2008
Croatia A783192 14-Mar-2009
Rijeka,
15 ABEDEJOS, LYMIN BATAN FITTER FILIPINO 11-Jan-1966 PASIG, RIZAL 19-Jun-2008
Croatia B301551 27-Dec-2010
Rijeka,
16 CRISTOBAL, CRISTOPHER FERRER
OILER FILIPINO 17-Sep-1975 ILOILO CITY 19-Jun-2008
Croatia B220084 04-May-2010
Rijeka,
17 RAMIREZ, REYNALD ELICOT OILER FILIPINO 27-Jul-1967 TAGBILARAN CITY 19-Jun-2008
Croatia B0559516 21-May-2013
Rijeka,
18 CASTILLA, RYAN PATRICK GAONA WIPER FILIPINO 29-Sep-1981 MANILA 19-Jun-2008
Croatia A949733 29-Mar-2009
MINGLANILLA, Rijeka,
19 SAYSON, JOSEPH VALCORZA C/COOK FILIPINO 31-Jan-1970
CEBU
19-Jun-2008
Croatia B217936 19-Apr-2010
Rijeka,
20 DRAPER, EDUARDO QUIRAO MESSMAN FILIPINO 27-Aug-1968 QUEZON CITY 19-Jun-2008
Croatia B0162700 07-May-2011
PASIG, METRO Rijeka,
21 TAGOD, BILLY SALVO D/CDT FILIPINO 11-Apr-1983
MANILA
19-Jun-2008
Croatia B0527499 22-Jan-2013
Rijeka,
22 GALORIO, OMEGA ANDREW SABIDO
E/CDT FILIPINO 22-Oct-1984 LANAO DEL NORTE 19-Jun-2008
Croatia B0536516 02-Apr-2013

23

IMO FAL
Form 5

12. Date and sign by the master, authorized agent or officer

C97 Capt. RYSZARD IGNATOWICZ
Master
29-01-2009
 乗　組　員　名　簿
CREW LIST

到着 出発 Page No. 1 / 1
X Arrival Departure
1. 船舶の名称 2. 到着港※／出発港※ 3. 到着日※／出発日※
Name of ship Port of arrival Date of arrival

M/V "ANDINO" YOKOHAMA 27-01-2009

4. 船舶の国籍 5. 前寄港地※ 6. 身分証明書（乗員手帳）
Nationality of ship Port arrived from の
GERMAN SAN ANTONIO, CHILE 種類及び番号
Nature and No. of identity
7. 番号 8. 氏名 9. 職名 10. 国籍 １ 11. 生年月日、出生地※ document
No. Family name, given names Rank or ra- Natio- Date and place of birth (Seaman's Passport with
ting nality Date of Expiry - dd.mm.yy)

1 CHWIEDUK, ANDRZEJ MASTER POLISH 30.11.57 PYSKOWICE AF0853632 29.01.13

2 STOLYAROV, VADYM C/OFF UKRAINIAN 24.03.76 UKRAINE AH832082 09.07.11

3 ROBLES, ROSAURO MEDINA 2/OFF FILIPINO 04.06.70 MANILA XX1025611 23.04.13

4 BEDNAREK, MALGORZATA ANNA 3/OFF POLISH 16.10.82 WROCLAW AS9059366 02.10.16

5 DOBRZANSKI, ROMAN BOGDAN C/ENG POLISH 02.06.57 PRABUTY BM4789059 28.10.09

6 FLOROI, FLORIN CONSTANTIN 2/ENG ROMANIAN 11.04.71 BRASOV 09767138 18.02.10

7 ANDRASZEWICZ, DARIUSZ SEBASTIAN 3/ENG POLISH 10.09.81 SZCZECIN AD7064101 11.03.12

8 PRZYBYLSKI, ROMAN WOJCIECH ELEC POLISH 25.09.54 GDYNIA BM5524822 16.03.10

VICTORIA, ORIENTAL
9 CASTILLO, ROMEO ATIENZA BOSUN FILIPINO 04.12.63 MINDORO QQ0694262 27.07.10

10 PADILLO, JOVENSON SALAR A/B FILIPINO 31.12.75 MATALOM, LEYTE QQ0111404 18.04.10
NASUGBU,
11 JACA, MANOLO JR DIMAFELIX A/B FILIPINO 03.04.72 BATANGAS TT0730757 17.08.11

12 CASTRO, DANIEL DE LEON A/B FILIPINO 23.11.61 MANILA PP0756483 03.02.10

SAN FRANCISCO,
13 TY, DANIEL JR. LAO O/S FILIPINO 27.07.74 SOUTHERN LEYTE UU0060419 19.10.11

14 BACOL, FELIZARDO ESGUERRA O/S FILIPINO 17.09.82 BUTUAN CITY SS0861620 30.03.11

15 ABEDEJOS, LYMIN BATAN FITTER FILIPINO 11.01.66 PASIG, RIZAL PP0640172 24.01.10

16 CRISTOBAL, CRISTOPHER FERRER OILER FILIPINO 17.09.75 ILOILO CITY PP0946630 03.03.10

17 RAMIREZ, REYNALD ELICOT OILER FILIPINO 27.07.67 TAGBILARAN CITY QQ0766183 22.07.10

18 CASTILLA, RYAN PATRICK GAONA WIPER FILIPINO 29.09.81 MANILA SS0766517 30.03.11

19 SAYSON, JOSEPH VALCORZA C/COOK FILIPINO 31.01.70 MINGLANILLA, CEBU QQ0252143 21.04.10

20 DRAPER, EDUARDO QUIRAO MESSMAN FILIPINO 27.08.68 QUEZON CITY RR0289836 27.10.10
PASIG, METRO
21 TAGOD, BILLY SALVO D/CDT FILIPINO 11.04.83 MANILA VV0832830 21.11.12

22 GALORIO, OMEGA ANDREW SABIDO E/CDT FILIPINO 22.10.84 LANAO DEL NORTE XX0984703 18.04.13

12. 日付及び船長又は委任を受けた代理人若しくは船舶の職員による署名
Date and signature by master, authorized agent or officer

27-01-2009
Capt. ANDRZEJ CHWIEDUK
（注）　　※の付されている項目については記入不要。
Note　　It is not necessary to fill in the item marked “ ※”.
 乗　組　員　名　簿
CREW LIST

到着 出発 Page No. 1 / 1
Arrival X Departure
1. 船舶の名称 2. 到着港※／出発港※ 3. 到着日※／出発日※
Name of ship Port of arrival Date of arrival
M/V "ANDINO" YOKOHAMA 27-01-2009
4. 船舶の国籍 5. 前寄港地※ 6. 身分証明書（乗員手帳）
Nationality of ship Port arrived from の
GERMAN SAN ANTONIO, CHILE 種類及び番号

Nature and No. of identity

7. 番号 8. 氏名 9. 職名 10. 国籍 １ 11. 生年月日、出生地※ document
No. Family name, given names Rank or ra- Natio- Date and place of birth (Seaman's Passport with
ting nality Date of Expiry - dd.mm.yy)

1 IGNATOWICZ, RYSZARD MASTER POLISH 03.07.49 WLOKI AS4164429 20.11.16

2 STOLYAROV, VADYM C/OFF UKRAINIAN 24.03.76 UKRAINE AH832082 09.07.11

3 ROBLES, ROSAURO MEDINA 2/OFF FILIPINO 04.06.70 MANILA XX1025611 23.04.13

4 BEDNAREK, MALGORZATA ANNA 3/OFF POLISH 16.10.82 WROCLAW AS9059366 02.10.16

5 DOBRZANSKI, ROMAN BOGDAN C/ENG POLISH 02.06.57 PRABUTY BM4789059 28.10.09

6 FLOROI, FLORIN CONSTANTIN 2/ENG ROMANIAN 11.04.71 BRASOV 09767138 18.02.10

7 ANDRASZEWICZ, DARIUSZ SEBASTIAN 3/ENG POLISH 10.09.81 SZCZECIN AD7064101 11.03.12

8 PRZYBYLSKI, ROMAN WOJCIECH ELEC POLISH 25.09.54 GDYNIA BM5524822 16.03.10

VICTORIA, ORIENTAL
9 CASTILLO, ROMEO ATIENZA BOSUN FILIPINO 04.12.63 MINDORO QQ0694262 27.07.10

10 PADILLO, JOVENSON SALAR A/B FILIPINO 31.12.75 MATALOM, LEYTE QQ0111404 18.04.10
NASUGBU,
11 JACA, MANOLO JR DIMAFELIX A/B FILIPINO 03.04.72 BATANGAS TT0730757 17.08.11

12 CASTRO, DANIEL DE LEON A/B FILIPINO 23.11.61 MANILA PP0756483 03.02.10

SAN FRANCISCO,
13 TY, DANIEL JR. LAO O/S FILIPINO 27.07.74 SOUTHERN LEYTE UU0060419 19.10.11

14 BACOL, FELIZARDO ESGUERRA O/S FILIPINO 17.09.82 BUTUAN CITY SS0861620 30.03.11

15 ABEDEJOS, LYMIN BATAN FITTER FILIPINO 11.01.66 PASIG, RIZAL PP0640172 24.01.10

16 CRISTOBAL, CRISTOPHER FERRER OILER FILIPINO 17.09.75 ILOILO CITY PP0946630 03.03.10

17 RAMIREZ, REYNALD ELICOT OILER FILIPINO 27.07.67 TAGBILARAN CITY QQ0766183 22.07.10

18 CASTILLA, RYAN PATRICK GAONA WIPER FILIPINO 29.09.81 MANILA SS0766517 30.03.11

19 SAYSON, JOSEPH VALCORZA C/COOK FILIPINO 31.01.70 MINGLANILLA, CEBU QQ0252143 21.04.10

20 DRAPER, EDUARDO QUIRAO MESSMAN FILIPINO 27.08.68 QUEZON CITY RR0289836 27.10.10
PASIG, METRO
21 TAGOD, BILLY SALVO D/CDT FILIPINO 11.04.83 MANILA VV0832830 21.11.12

22 GALORIO, OMEGA ANDREW SABIDO E/CDT FILIPINO 22.10.84 LANAO DEL NORTE XX0984703 18.04.13

12. 日付及び船長又は委任を受けた代理人若しくは船舶の職員による署名
Date and signature by master, authorized agent or officer

29-01-2009
Capt. RYSZARD IGNATOWICZ
（注）　　※の付されている項目については記入不要。
Note　　It is not necessary to fill in the item marked “※”.
 IMO PASSENGER LIST
Page no.

x Arrival Departure
1 of 1
1.Name of ship 2. Port of arrival 3. Date of arrival

FINO PIRAEUS 07.03.2022

4. Nationality of ship 5. Port arrived from 6.Nature and
No. of identity
LIBERIA AVONMOUTH document
(seaman's
7.No 8. Family names ; given names 9.Rank or rating 10.Nationality 11. Date and place of birth passport)
IMO Convention on Facilitation of International Marine Traffic

1
2
3
4
5
6
7
8
9
10
11
12 NIL
13
14
15
16
17
18
19
20
21
22
23
24
25
12. Date and signature by master,authorized agent or officer
07.03.2022 Capt. Vladimir Kolosov
Master
 IMO CREW'S EFFECTS DECLARATION

PAGE 1 of 1
1. Name of ship 2. Port of Arrival 3. Date of Arrival

FINO PIRAEUS 07.03.2022

4. Nationality of ship/Flag 5. Port arrived from

LIBERIA AVONMOUTH
6. No. 7. Family name, given names 8. Rank or rating 9. Effects which are dutiable or subject to prohibitions or restrictions 10. Signature

CIG Beer Spirit Wine

1 Kolosov Vodymyr MASTER

2 Stolyarov Vadym C/OFF

3 Dernovoy Sergiy 2/OFF

4 Shmalko Oleksandr 3/OFF

5 Dalezios Georgios C/ENG

6 Bochkar Ivan 2/ENG

7 Dimitras Nikolas 3/ENG

8 Kyzyma Oleksiy 3/ENG

9 Pylypenko Sergiy EL.ENG

10 Todorashko Vitaliy BOSUN

11 Patseriuk Maksym A/B

12 Radchenko Sergiy A/B

13 Nikulin Artur O/S

14 Nikulin Artur O/S

15 Sviderskyi Nazar OILER

16 Skrypnyk Pavlo OILER

17 Kostiakov Serii WIPER

8. Date and Signature by Master, Authorized Agent or of

* e.g. wines, spirits, cigarettes, tobacco, etc.

07.03.2022
Capt. Kolosov Vladimir
 乗組員携帯品申告書
CREW’S EFFECTS DECLARATION

Page No 1
1. 船舶の名称 2. 関税等の免除が認められないもの又は日本へ
Name of ship の
M/V "ANDINO" 持込みが禁止若しくは制限されているもの
Effects ineligible for relief from customs duties and taxes or subject to prohibitions or restrictions

3. 船舶の国籍
Nationality of ship 酒類 たば 銃砲 その他
GERMAN こ 刀剣類
Alcoholic Tobacco Firearms Others
Beverage Products/ or Swords
s Cigarette
s
4. 番号 5. 氏名 6. 職名 数量 数量 数量 品名、数量、価格 7. 署名
No Family name, given names Rank or 本 本又は瓦 箇 Articles, Quantity, Value Signature
rating Bottle Piece or Number
Gram
0
1 CHWIEDUK, ANDRZEJ MASTER

0
2 STOLYAROV, VADYM C/OFF

0
ROBLES, ROSAURO
3 MEDINA
2/OFF

BEDNAREK, 0
4 MALGORZATA ANNA
3/OFF

DOBRZANSKI, ROMAN 0
5 BOGDAN
C/ENG

FLOROI, FLORIN 0
6 CONSTANTIN
2/ENG

ANDRASZEWICZ, 0
7 DARIUSZ SEBASTIAN
3/ENG

PRZYBYLSKI, ROMAN 0
8 WOJCIECH
ELEC

CASTILLO, ROMEO 0
9 ATIENZA
BOSUN

PADILLO, JOVENSON 0
10 SALAR
A/B

JACA, MANOLO JR 0
11 DIMAFELIX
A/B

CASTRO, DANIEL DE 0
12 LEON
A/B

0
13 TY, DANIEL JR. LAO O/S

BACOL, FELIZARDO 0
14 ESGUERRA
O/S

ABEDEJOS, LYMIN 0
15 BATAN
FITTER

CRISTOBAL, 0
16 CRISTOPHER FERRER
OILER

RAMIREZ, REYNALD 0
17 ELICOT
OILER

CASTILLA, RYAN #REF!

18 PATRICK GAONA
WIPER

SAYSON, JOSEPH #REF!

19 VALCORZA
C/COOK

DRAPER, EDUARDO #REF!

20 QUIRAO
MESSMAN

#REF!
21 TAGOD, BILLY SALVO D/CDT

GALORIO, OMEGA #REF!

22 ANDREW SABIDO
E/CDT

23
8. 日付及び船長又は委任を受けた代理人若しくは船舶の職員による署名
Date and signature by master, authorized agent or officer

27-01-2009 Capt. ANDRZEJ CHWIEDUK

（注）　　日本の免税範囲等について不明な場合は、所持品すべてを記入し、その旨を税関職員に伝えてください。
Note　　When you are not sure of the duty-free allowance in Japan, fill in all the articles you have and remind it to a customs officer.
 LIST OF NARCOTICS
xArrival oDeparture Page No :
0 1 of 1
1. Name of Ship 2. Port of arrival / departure 3.Date of arrival
M/V "ANDINO" YOKOHAMA, JAPAN 27-01-2009
4. Nationality of Ship : 5. Port arrival from / Port of destination :
GERMAN SAN ANTONIO, CHILE / NAGOYA, JAPAN
6. Number of person on board : 7. Period of stay 8. Place of storage
22 1 Day Master's Safe
No Qtty. Name Expiry

1 80 tab. Codeine phosphate 30mg Oct-2012

Date and signature of master, agent or authorized officer MASTER

27-01-2009 Capt. ANDRZEJ CHWIEDUK

CUSTOMS FORM
 IMO SHIP’S STORES DECLARATION
✘ Arrival Departure Page No.
1 of 1
1. Name of ship 2. Port of arrival 3. Date of arrival

M/V "ANDINO" YOKOHAMA, JAPAN 27-01-2009

4. Nationality of ship 5. Port arrived from/Port of destination

GERMAN SAN ANTONIO, CHILE / NAGOYA, JAPAN

6. Number of persons on board 7. Period of stay 8. Place of storage*

22 1 Day VARIOUS STORES

9. Name of article 10. Quantity 11. For Official use

GENERAL ( PAINT STORE )

Paint 1043 Liters
Paint, Additives, Thinners 176 Liters
Fuel Oil MT
Diesel Oil MT
Lubricating Oil Liters
IMO Convention on Facilitation of Maritime Traffic

STEWARD
Cereal & Paste 325 Kgs
Coffee 5 Bottles
Tea 3 Box
Eggs 180 Dozens
Fish – frozen, fresh, & salted 80 Kgs
Fruits – fresh, dried & canned 190 Kgs
Meat – fresh, canned & salted 200 Kgs
Vegetable – fresh, frozen & canned 210 Kgs
Poultry 100 Kgs
Sugar 43 Kgs

BONDED
Cigarettes 122 Reams
Beer 34 Cases
Wine 32 0.7L Bottles
Wine 1 1.0L Ctn.

12. Date and signature by master, authorized agent or

officer

27-01-2009
Capt. ANDRZEJ CHWIEDUK
IMO FAL Form3
 船　用　品　目　録
SHIP’S STORES DECLARATION
到着 出発 Page No. 1 / 1
X Arrival Departure
1. 船舶の名称 2. 到着港※／出発港※ 3. 到着日※／出発日※
Name of ship Port of arrival/departure Date of arrival/departure

M/V "ANDINO" YOKOHAMA 27-01-2009

4. 船舶の国籍 5. 前寄港地※／次寄港地※
Nationality of ship Port arrived from/Port of destination

GERMAN SAN ANTONIO, CHILE / NAGOYA, JAPAN

6. 乗船者数※ 7. 停泊期間※ 8. 保管場所※
Number of persons on board Period of stay Place of storage

22 1 Day BONDED STORE, BRIDGE, LIFEBOATS, & MASTER’S SAFE

9. 品名 10. 数量 11. 税関記入欄
Name of article Quantity Official use
燃料油等／Oil 燃料油／Fuel Oil mt
潤滑油／Lubricating Oil liters

遭難救命具等 ／Life 遭難ロケット

Preservers ／Distress Rockets 41
(Parachutes & Handflares) pieces
遭難弾／Distress Bombs Nil
救命捜索発射銃
／Guns of Life Saving Rope 4
(Line Throwing Apparatus) pieces

酒類／Liquors ウイスキー／Whisky Nil

ブランデー／Brandy Nil
ビール／Beer 22 c/s
Wine 34 btls x 0,7 ltr
4 x 1.0 ltr
たばこ／Tobacco 紙巻たばこ／Cigarettes 110 x 200
葉巻たばこ／Cigars Nil
たばこ／Tobacco Nil

銃砲、刀剣類 ／ 小銃／Rifles Nil

Firearms, Swords
けん銃／Revolvers Nil
弾薬／Cartridges Nil

医薬用麻薬類 ／ モルヒネ／Morphine Nil

Medical Narcotics
コカイン／Cocaine Nil
コデイン／Codeine 80 tabs
オピウム／Opium Nil

12. 日付及び船長又は委任を受けた代理人若しくは船舶の職員による署名
Date and signature by master, authorized agent or officer

27-01-2009
（注）　　※の付されている項目については記入不要。 Capt. ANDRZEJ CHWIEDUK
Note　　It is not necessary to fill in the item marked “※”
 VOYAGE MEMO - PORT OF CALL LIST
IF YOU
(Name of shipping line, agent, etc.) BUTTON
NSC Schifffahrtsgesellschaft mbH & Cie.KG, Hamburg, Germany ALL UPD
AUTOM
X Arrival Departure
1. Name of ship 2. Port of arrival / departure 3. Date of arrival / departure
M/V "ANDINO" YOKOHAMA 27-01-2009
4. Nationality of ship 5. Port arrived from 6. Destination

GERMAN SAN ANTONIO NAGOYA

Name of port Country Date of arrival Date of departure For official use

SAN ANTONIO CHILE 26-12-2008 26-12-2008

IQUIQUE CHILE 23-12-2008 24-12-2008
CALLAO PERU 21-12-2008 22-12-2008
YOKOHAMA JAPAN 27-11-2008 27-11-2008
NAGOYA JAPAN 26-11-2008 26-11-2008
YOKOHAMA JAPAN 24-11-2008 25-11-2008
SAN ANTONIO CHILE 18-10-2008 18-10-2008
CALLAO PERU 12-10-2008 13-10-2008
NAGOYA JAPAN 19-09-2008 20-09-2008
YOKOHAMA JAPAN 16-09-2008 18-09-2008
SAN ANTONIO CHILE 20-08-2008 21-08-2008
CALLAO PERU 15-08-2008 16-08-2008
YOKOHAMA JAPAN 24-07-2008 25-07-2008
NAGOYA JAPAN 22-07-2008 23-07-2008
SHANGHAI CHINA 18-07-2008 19-07-2008
PORT SAID EGYPT 01-07-2008 01-07-2008
RIJEKA (3. MAJ) CROATIA NEWBUILDING 26-06-2008

27-01-2009 Capt. ANDRZEJ CHWIEDUK

ST
IF YOU USE "NEXT PORT"
BUTTON ON "DATA" SHEET,
ALL UPDATE HERE IS
AUTOMATIC !!!

For official use

 NIL DECLARATIONS

X Arrival oDeparture Page No :

NSC Schifffahrtsgesellschaft mbH & Cie. KG 1 of 1

1. Name of Ship 2. Port of arrival 3.Date of arrival

M/V "ANDINO" YOKOHAMA, JAPAN 27-01-2009

4. Nationality of Ship : 5. Port arrival from / Port of destination :

GERMAN SAN ANTONIO, CHILE / NAGOYA, JAPAN

6. Number of person on board : 7. Period of stay 8. Place of storage

22 1 Day

PASSENGERS NIL

ARMS AND AMUNITIONS NIL

ANIMALS AND BIRDS NIL

STOWAWAYS NIL

RADIOACTIVE MATERIAL NIL

MILITARY CARGOES NIL

Date and signature of master, agent or authorized officer

27-01-2009 Capt. ANDRZEJ CHWIEDUK

Master
CUSTOMS FORM
 VACCINATION LIST
(Name of shipping line, agent, etc.)

NSC Schifffahrtsgesellschaft mbH & Cie.KG, Hamburg, Germany

X Arrival Departure
1. Name of ship 2. Port of arrival / departure 3. Date of arrival / departure
M/V "ANDINO" YOKOHAMA 27-01-2009
4. Nationality of ship 5. Port arrived from 6. Destination
GERMAN SAN ANTONIO NAGOYA
7. No. 8. Family name; given names & middle initial. 9. Rank or rating 10. Yellow fever vaccination and validity 11. for official use

1 CHWIEDUK, ANDRZEJ MASTER 02-Jul-2005 02-Jul-2015

2 STOLYAROV, VADYM C/OFF 30-May-2001 30-May-2011

3 ROBLES, ROSAURO MEDINA 2/OFF 10-Oct-2003 10-Oct-2013

4 BEDNAREK, MALGORZATA ANNA 3/OFF 24-Oct-2006 24-Oct-2016

5 DOBRZANSKI, ROMAN BOGDAN C/ENG 19-Sep-2006 19-Sep-2016

6 FLOROI, FLORIN CONSTANTIN 2/ENG 22-Sep-2008 22-Sep-2018

7 ANDRASZEWICZ, DARIUSZ SEBASTIAN 3/ENG 03-Feb-2004 03-Feb-2014

8 PRZYBYLSKI, ROMAN WOJCIECH ELEC 10-Aug-1999 10-Aug-2009

9 CASTILLO, ROMEO ATIENZA BOSUN 11-Jan-2002 11-Jan-2012

10 PADILLO, JOVENSON SALAR A/B 05-Jan-2001 05-Jan-2011

11 JACA, MANOLO JR DIMAFELIX A/B 31-Mar-1999 31-Mar-2009

12 CASTRO, DANIEL DE LEON A/B 10-Jan-2003 10-Jan-2013

13 TY, DANIEL JR. LAO O/S 06-Feb-2007 06-Feb-2017

14 BACOL, FELIZARDO ESGUERRA O/S 08-May-2006 08-May-2016

15 ABEDEJOS, LYMIN BATAN FITTER 22-Jun-2007 22-Jun-2017

16 CRISTOBAL, CRISTOPHER FERRER OILER 28-Jul-2006 28-Jul-2016

17 RAMIREZ, REYNALD ELICOT OILER 17-Jan-2003 17-Jan-2013

18 CASTILLA, RYAN PATRICK GAONA WIPER 31-Mar-2006 31-Mar-2016

19 SAYSON, JOSEPH VALCORZA C/COOK 07-May-2008 07-May-2018

20 DRAPER, EDUARDO QUIRAO MESSMAN 25-Sep-2006 25-Sep-2016

21 TAGOD, BILLY SALVO D/CDT 14-Feb-2008 14-Feb-2018

22 GALORIO, OMEGA ANDREW SABIDO E/CDT 27-May-2008 27-May-2018

12. Date and signature by master, authorized agent or officer

27-01-2009 Capt. ANDRZEJ CHWIEDUK

様式第一（第三条関係）

明　 　　　 　　告　　　 　 　　書 （船 舶 用）

MARITIME DECLARATION OF HEALTH

（全て記入し、外国の港から到着する船舶の長が所管官庁に提出すること）
(To be completed and submitted to the competent authorities by the masters of ships arriving from foreign ports.)

提出する港名 年　月　日
Submitted at the port of YOKOHAMA, JAPAN Date 27-01-2009

船　　名 登録/IMO番号 発航地名 行先地名

Name of ship M/V Andino Registration/IMO No 9358888 arriving from SAN ANTONIO, CHILEsailing to NAGOYA, JAPAN

国　　籍 船　長　の　氏　名
Nationality GERMAN Master's name Capt. ANDRZEJ CHWIEDUK

総トン数
Gross tonnage 40,628

有効な船舶衛生管理免除/船舶衛生管理証明書を所持しているか。 はい いいえ
Valid Sanitation Control Exemption/Control Certificate carried on board? yes

発行元 日付 再検査は必要か。 はい いいえ

Issued at Yokohama, Japan Date 25-11-2008 Re-inspection required? no

世界保健機関が認定する汚染地域に寄港したか。 はい いいえ
Has ship visited an affected area identified by the World Health Organization? no

寄航港及び日付
Port and date of visit

発航日以降又は過去三十日以内のいずれか短い方の期間内に寄航した港
List ports of call from commencement of voyage with dates of departure, or within past thirty days, whichever
is shorter: Kindly see attached ports of call list

到着港の検疫所から要請があった場合、国際航行の発航日以降又は過去三十日以内のいずれか短い方の期間内に乗組員、乗客
その他船舶に乗船していた者を列挙すること。同期間内に寄航した港／国もすべて記入すること（書き切れない場合は添付書に
氏名を追加すること）
　Upon request of the Quarantine Station at the port of arrival, list crew members, passengers or other persons who have joined
ship since international voyage began or within past thirty days, whichever is shorter, including all ports/countries visited in
this period (add additonal names to the attached schedule):
氏名 　乗船地
（１）name joined from: （１） （２） （３）
氏名 　乗船地
（１）name joined from: （１） （２） （３）
氏名 　乗船地
（１）name joined from: （１） （２） （３）

乗船している乗組員の数 乗船している乗客数
Number of crew members on board 22 Number of passengers on board NIL
 保健上の質問
Health Qustions

### １．航海中船内で事故による以外の死亡者があったか。あれば別表に詳細に記入すること。 はい いいえ

Has any person died on board during the voyage* otherwise than as a result of accident? no
If yes, state particulars in attached schedule.
総死亡者数
Total no. of deaths

2．感染性のものであるという疑いをかけた疾病の患者が船内にあるか、又は航海中にあったか。 はい いいえ
あれば別表に詳細に記入すること。 no
Is there on board or has there been during the international voyage* any case of disease which you
suspect to be of an infectious nature? If yes, state particulars in attached schedule.

３．航海中、病気になった乗客の総数は通常／予想よりも多かったか。 はい いいえ
Has the total number of ill passengers during the voyage been greater than normal/expected? no
病人の数は何名か。
How many ill persons?

４．現在船内に病人があるか。あれば別表に詳細に記入すること。 はい いいえ
Is there any ill person on board now? If yes, state particulars in Schedule. no

５．医師の診断があったか。あれば治療内容及び助言の詳細を別表に記入すること。 はい いいえ
Was a medical practitioner consulted? If yes, state particulars of medical treatment or advice provided no
in attached schedule.

６．そのほか、船内で疾病の感染又は拡大の原因となるものがあるか。あれば別表に詳細に記入すること。 はい いいえ
Are you aware of any condition on board which may lead to infection or the spread of disease? no
If yes, state particulars in attached schedule.

７．船内で保健措置（検疫、隔離、消毒、除染など）が施されたか。施されていれば、種類、場所、日付を はい いいえ
記載すること。 no
Has any sanitary measure(e.g. quarantine, isolation, disinfection or decontamination) been applied on
board? If yes, specify type, place and date.

８．船内に密航者の乗船があったか。あればどこで乗船したか記載すること（わかる範囲で）。 はい いいえ
Have any stowaways been found on board? If yes, where did they join the ship(if known)? no

９．船内に病気の動物又はペットがあったか。 はい いいえ
Is there a sick animal or pet on board? no

註 船医がいない場合、船長は、次の症状がある場合、感染性の疾病の存在を疑う根拠とみなさなければならない。
(a)数日間続く発熱と（ⅰ）衰弱（ⅱ）意識低下、（ⅲ）リンパ節の腫脹、（ⅳ）黄疸、（ⅴ）咳又は息切れ、（ⅵ）異常出血、又は（ⅶ）
麻痺のいずれかの症状を伴う場合。
(b)発熱の有無にかかわらず、（ⅰ）急性の発疹、（ⅱ）激しい嘔吐（船酔いは除く）、（ⅲ）激しい下痢、又は（ⅳ）頻発するけいれん
症状がある場合。
Note: In the absence of a surgeon, the master should regard the following symptoms as grounds for suspecting the e xistence
of a disease of an infectious nature:
(a)fever, persisting for several days or accompanied by (i) prostration; (ii) decreased consciousness; (iii) glandular
swelling; (iv) jaundice; (v) cough or shortness of breath; (vi) unusual bleeding; or (vii) paralysis.
(b) with or without fever: (i) any acute skin rash or eruption; (ii) severe vomiting (other than sea sickness);
(iii) severediarrhoea; or (iv) recurrent convulsions.

私は、この明告書（別表を含む。）に示された質問に対する詳細及び回答が私の知る限り、また、私の信じる限りにおいて真実で、
かつ、正確なものであることを、ここに宣言する。
I hereby declare that the particulars and answers to the questions given in this Declaration of Health (including the Schedule)
are true and correct to the best of my knowledge and belief.
署　名
Signed
船長又は権限のある代理人
Authorized Agent or Master
副　署
Countersigned N/A

船　　医
Ship's Surgeon
年月日
Date 27-01-2009
 インフルエンザ(H5N1)の確認内容
Cofirmation content of influenza
年 月 日
Date 27-01-2009
名古屋検疫所
Nagoya Quarantine Station

船名
Name of ship M/V Andino

船長の氏名
Master's
name Capt. ANDRZEJ CHWIEDUK

確　　認　　内　　容 有 無
Cofirmation content Yes No
(1)３８℃以上の発熱及び急逝呼吸器症状を呈している者の有無。
Presence of patients with severe acute febrile respiratory illness
(e.g.,fever ＞３８℃, cough, shortness of berth). No

(2)原因不明の肺炎や呼吸困難を呈している者の有無。
Presence of persons with unxplained pneumonia or difficulty of breathing.
No

(3)原因不明の死亡者の有無。
Presence of the dead with unxplained illness.
No

(4)１０日以内に死鳥、インフルエンザ(H5N1)に感染している、又はその疑いがある鳥
　　（鶏、あひる、七面鳥、うずら等）との接触歴を有する者の有無。
Presence of persons with exposure history to dead or infected birds for known or suspected
influenza(H5N1)within the prior 10 days.
No
(5)10日以内にインフルエンザ(H5N1)患者（疑い例も含む）との接触歴を有する者の有無。
Presence of persons with exposure history to known or suspected influenza (H5N1) patients
within the prior 10 days. No

※（１）～（５）の通報内容について「有」と回答した場合は、別途その詳細について報告すること。

　　Report details separately when answered "Yes".

009
 Pre-arrival Procedure Format（Page1）
【Unified Format for Captain of the Port, The Port Management Body, District Transport Bureau, and Japan Coast Guard office】

□Application to load/discharge dangerous goods　　　　■Application for berth assignment　　　□Application for berth change
■Application for moorings　■Report on the Financial Security Information based on the Law on liability for Oil Pollution Damage
■Report on the Security Information of Ships based on the Law for the Security of Ships and of Port Facilities
※ You can use this format as a Report on the Security Information of Ship based on the Law for the Security of Ships and of Port Facilities , a Report on the Financial
Security Information based on the Law on Liability for Oil Pollution Damage , and Applica

Captain of the Port □

The Port Management Body □
Director General of the District □
Transport Bureau
Chief of Coast Guard □
(office or station)
Name of master ANDRZEJ CHWIEDUK
Name of applicant MASTER
Address of applicant M/V ANDINO
【　Coastal　・　Oceangoing　】 Name of the person in charge/contact address

Name of ship IMO number (or number of ship/fishing boat registration number）
ANDINO 9358888
Type 【 CAR CARRIER ・ container vessel ・ cargo vessel ・ passenger vessel ・ oil tanker ・ fishing vessel ・ other 】　
of ship 【 S.S.　・　(M.S).　・　sailing ship with engine　・　other 】
Basic Flag state Port of registry
information
GERMAN HAMBURG
Gross tonnage International gross tonnage Dead weight tonnage Length overall
40628 12303 176
Communication Call sign Other communication systems
system
DFRH2 MMSI: 218726000; Ship's e-mail: [email protected]
Ship’s owner
<Name> MS "MONZA" SCHIFFFAHRTSGESELLSCHAFT MBH & CIE.KG

<Address> VAN-DER-SMISSEN-STRASSE 9, 22767 HAMBURG, GERMANY

<TEL , FAX> TEL: +49 40 80 80 53 500 FAX: +49 40 80 80 53 800

Ship’s operator (When the ship’s operator is different from the ship’s leaseholder, you should also include the ship’s leaseholder.）
Owner, <Name> NSC Sschifffahrtsgesellachaft mbH & Cie. KG
operator,
and agent <Address> VAN-DER-SMISSEN-STRASSE 9, 22767 HAMBURG, GERMANY
<TEL , FAX>
Ship’s agent
<Name> DAITO CORPORATION, YOKOHAMA BRANCH
<Address> A-5 ,9, Honmoku Futo, Naka-ku, Yokohama, 231-0811, JAPAN
<TEL , FAX> TEL: +81-45-621-3548 FAX: +81-45-622-9421
Port of arrival Expected date and time of arrival of the ship in port
YOKOHAMA 27-01-2009
Purpose to berth Anchorage ground desired Period of anchorage
LOADING 3 days
Moorings of arrival <Code>

Date-time of arrival Date-time of departure

Arrival 27-01-2009 29-01-2009
information
Berth change from Berth change to

Reason for the berth change Date and time of the berth change Period of stay
1 day

In or Shift Port or Starboard　　　　　　　　　　　　　　　　　　　　　

【　In　・　Shift　】 【Starboard　】
Name of ship which lays aboard or laid aboard Maximum draft
NIL 7.3 （m）
Name of line (Service)
【　Priority for berthing　・　Liner　・　Tramper　】
CCNI
Port of provenance Last port Next port Port of destination
Voyage SAN ANTONIO, CHILE SAN ANTONIO, CHILE NAGOYA, JAPAN NAGOYA, JAPAN
information
Entry position into specific area and ETA
<Position>　【　 Tokyo Bay　・　 Ise Bay　・　 Kii Channel　・　 Bungo Cnannel　・　 Kanmon Channel　】
<Date and time> 26-01-2009
Name of ship IMO number(or number of ship/fishing boat registration number）
ANDINO 9358888

Landing cargo in this country Cargo on board

<Name・Port of loading> <Quantity> <Name> <Quantity>

Port of NIL
arrival TOKYO,
Cargo JAPAN
information

Other ports
(when the port of
arrival is the first
port in this
country.)

Proper shipping name(Port of loading), Class, UN number, Packing group, Number of packages,
Mass net Stowage position on board
Flash point( IN℃,c.c.)

arrival NIL

Dangerous
goods
information

departure NIL

Dangerous goods handling agent’s name and telephone number

Dangerous
goods Period of dangerous goods handling
handling
information NIL

Holder of financial security Certificate number ( if you possess certificate issued by MLIT or CLC certificated issued by foreign country.)
【 (Yes) / No 】

①Name of insurer or guarantor NORTH OF ENGLAND P&I ASSOCIATION LIMITED

②ID number of the certificate issued by the

insurer or guarantor 2008/3787
Financial
Security Fill in these items unless you ③Duration of insurance or other financial
information possess the certificate security
26 JUNE 2008 TO 20 FEBRUARY 2009
mentioned above.
④Does financial security cover both bunker oil pollution damage and the coast of
【　Yes 　】
shipwreck
⑤Amount limit of insurance or other financial
security

Record of entering Japanese port within past 1 year　　　　　　　Yes　　　　　

Remarks Kindly see Last 10 Ports of Call below.

 Pre-arrival Procedure Format（Page２）
Name of ship IMO number(or number of ship/fishing boat registration number）
Andino 9358888

Report on Equipment of ship security alert system Ship’s operating security level Date, time and location of the ship at the time the report is made　
The security 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　
information
of ship 【　Yes　】 1 (ONE) <Date and time> 14-11-2008 0000 UTC
<Position> N ( 22-30 ) E ( 167-30 )
Number of ISSC and name of its issuing Name and contactpoint of Company Security Name and position of Ship Security Officer　　　　　　　　　　　　　　　
authority Officer 　　　　　　　　　　　　　　　　　　　　　　　
<Number> 112412/178/08 <Name> Mr.BERND RIEPER <Name> ANDRZEJ CHWIEDUK

<Issuing authority> GERMANISCHER LLOYD <Contactpoint> 00 491622194319 <Position> MASTER

Extended Japanese domestic voyage　　　 　　　　　　　　　　　　　　　　　　　　【 　Yes　 / 　 No 　 】

All ports of call in Japan after departure and schedule of entrance

①<Port of call> <Berth>
NAGOYA KINJYO PIER
<Time and date> 30-01-2009
②<Port of call>　 <Berth>

<Time and date>

③<Port of call>　 <Berth>

<Time and date>

④<Port of call>　 <Berth>

<Time and date>

⑤<Port of call>　 <Berth>

<Time and date>

Entry position into specific area and ETA after departure　
　①<Entry position> 　②<Entry position>

　　【 Tokyo Bay / Ise Bay / Kii Channel / 　　【 Tokyo Bay / Ise Bay / Kii Channel /

Bungo Channel / Kanmon Channel　】 Bungo Channel / Kanmon Channel　】

<Time and date> 30-01-2009 <Time and date>
　③<Entry position> 　④<Entry position>
　　【 Tokyo Bay / Ise Bay / Kii Channel / 　　【 Tokyo Bay / Ise Bay / Kii Channel /
Bungo Channel / Kanmon Channel　】 Bungo Channel / Kanmon Channel　】
<Time and date> <Time and date>
※ Fill in these items on last ten ports of call
Name of country Name of port Date of arrival Date of departure
　① CHILE 　① SAN ANTONIO ① ① 26-12-2008
26-12-2008

　② CHILE 　② IQUIQUE ② ② 24-12-2008

23-12-2008

　③ PERU 　③ CALLAO ③ ③ 22-12-2008

21-12-2008

　④ JAPAN 　④ YOKOHAMA ④ ④ 27-11-2008

27-11-2008

　⑤ JAPAN 　⑤ NAGOYA ⑤ ⑤ 26-11-2008

26-11-2008

　⑥ JAPAN 　⑥ YOKOHAMA ⑥ ⑥ 25-11-2008

24-11-2008

　⑦ CHILE 　⑦ SAN ANTONIO ⑦ ⑦ 18-10-2008

18-10-2008

　⑧ PERU 　⑧ CALLAO ⑧ ⑧ 13-10-2008

12-10-2008

　⑨ JAPAN 　⑨ NAGOYA ⑨ ⑨ 20-09-2008

19-09-2008

　⑩ JAPAN 　⑩ YOKOHAMA ⑩ ⑩ 18-09-2008

16-09-2008
 Ship security level at those ports Additional security measures Existence of passengers boarding at the port
and to disembark in Japan

　① 　①【 No 】<Detail> 　①【 No 】

1 (ONE)

　② 　②【 No 】<Detail> 　②【No 】

1 (ONE)

　③ 　③【 No 】<Detail> 　③【 No 】

1 (ONE)

　④ 　④【 No 】<Detail> 　④【 No 】

1 (ONE)

　⑤ 　⑤【 No 】<Detail> 　⑤【 No 】

1 (ONE)

　⑥ 　⑥【 No 】<Detail> 　⑥【 No 】

1 (ONE)

　⑦ 　⑦【 No 】<Detail> 　⑦【 No 】

1 (ONE)

　⑧ 　⑧【 No 】<Detail> 　⑧【 No 】

1 (ONE)

　⑨ 　⑨【 No 】<Detail> 　⑨【 No 】

1 (ONE)

　⑩ 　⑩【 No 】<Detail> 　⑩【 No 】

1 (ONE)

Cruising speed 19.7 All security incidents and other practical security related information

Crew List
Please attach Crew Lest filling all the necessary information.
(name, nationality, date of birth, seaman's passport No., rank or rating.)
Passenger List
Existence of passengers 【 Yes / No / Undetermined 】
Please attach Passenger List filling all the necessary information.
(name, nationality, date of birth, passport No., port of embarkation and disembarkation.)

１． Submit Page1 to all the offices you apply or report to. (If you use public moorings, you should submit Page1 when you apply for the public moorings.).
　 　　　　　　　　　　　
　　　 You should submit this format before either of the prior; by noon of the day before arrival or 24 hours before arrival. If the day you submit the format
is a holiday, you should submit before noon of the workday before the holiday. (Note; When you enter into specific area and ETA from a foreign port ,
"arrival" is replaced by "entry into specific area and ETA.”)
２． Submit page2 only to Japan Coast Guard if necessary. You should submit 24 hours before arrival.
３． When you apply to Captain of the Port, you should sign your name in “Name of applicant”.
４． For a coastal ship, fill in “Other communication system” only with a call sign.
５．“Record for entering Japanese port during the past year “includes the entrance into the specific area of the “Non-tanker-ships” within the past year.
６．Fill in "Port of loading" of "Cargo information" section and "Dangerous goods information" only when you enter from a foreign port.

７． A coastal ship does not need to fill in “Other ports in this country” of “Name, port of loading and quantity of landing cargo”

８． Dangerous Goods (DG) [if any]. Please notify us of “DG to be discharged” and “DG not to be discharged” on arrival, and “Loaded DG” on departure,
respectively. As for “DG not to be discharged”, please indicate the condition of the place where DG is stored, “OPEN” or “CLOSED”, in the column
of “Storage Position on Board”.
９． Dangerous Goods Handling information [if applicable]. It is to be written by the cargo handling agent.

10． When you choose "Yes" in "Extended Japanese domestic voyage (Yes, No)", you do not need to fill in both "All ports of call in Japan after departure
and schedule of entrance" and "Entry position into specific area and ETA after departure".
11． In Page2, when ports in Japan are included in past 10 ports, you can start the list with the latest port call in Japan.
 MARITIME DECLARATION OF HEALTH
(INTERNATIONAL FORM)
(To be rendered by the masters of ships arriving from ports outside the territory)

Port of: YOKOHAMA, JAPAN Date: 27-01-2009

Name Of Ship: M/V "ANDINO" From: SAN ANTONIO, CHILE To: NAGOYA, JAPAN

Nationality: GERMAN Master's Name Capt. ANDRZEJ CHWIEDUK

Net Registered Tonnage: 14163

Deratization or Certificate: Sanitation Control Exemption Certificate

Deratization
Exemption
Issued at: YOKOHAMA, JAPAN, 25-11-2008

Number of Cabin: NIL No. Of Crew 22

Passengers
Deck: NIL

List of ports of call from commencement of voyage with dates of departures:

Kindly see attached Ports of call list.

HEALTH QUESTIONS ANSWER YES or NO

1
Has there been on board during the voyage any case or suspected case of plaque, cholera, yellow fever, or
smallpox?
Give Particulars in the schedule. NO

2 Has Plaque occurred or been suspected among the rats or mice on board during the voyage or has there
been unusual mortality among them? NO

3 Has Any person died on board during the voyage otherwise than as a result of an accident?
Give particulars in the schedule NO

4 Is there on board or has there been during the voyage any case of illness which you suspect to be of an
infectious nature? NO

5 Is there Any sick person on board now? Give Particulars in the schedule.

NOTE In the absence of surgeon, the mate should regard the fallowing symptoms as ground for suspecting
the existence of infections disease: fever accompanied by prostration or persisting for several days or
accompanied by grandular swelling; or any recent appearance of skin eruption with or without fever, severe
diarrhoea with symptoms of collapse; jaundice accompanied by fever. NO

6 Are you aware of any other condition on board which may lead to infection or the spread of infectious
disease? NO

I hereby declare that the particulars and the answers to the questions given in this Declaration of health (Including the Schedule)
are the true and correct to the best of my knowledge and belief.

Signed:
MASTER

Countersigned: N/A

Ship's Surgeon

Date: 27-01-2009

If more than 4 weeks have elapsed since the voyage began, it will suffice to give particulars for the last 4 weeks.
 MINISTERIO DE SALUD
DIRECCION DE SALUD CALLAO
SANIDAD MARITIMA INTERNACIONAL

DECLARACION COMPLEMENTARIA DE SANIDAD MARITIMA

COMPLEMENTARY HEALTH MARITIME DECLARATION

PUERTO FECHA
PORT CALLAO DATE 27-01-2009

NAVE ULTIMO PUERTO

VESSEL ANDINO LAST PORT SAN ANTONIO, CHILE
NACIONALIDAD CAPITAN
NATIONALITY GERMAN MASTER Capt. ANDRZEJ CHWIEDUK

Declaro que en el transcurso del viaje, actualmente no se han presentado casos de tripulantes que presenten los
siguientes sintomas:
I declare that in the course of the trip at the moment the crew have not been present the fallowing symptoms:

1 FIEBRE
FEVER NO

2 MIALGIAS (DOLOR MUSCULAR)

MIALGIAS (MUSCULAR PAIN) NO

3 DIFICULTAD RESPIRATORIA
BREATHING DIFFICULTY NO

4 CEFALEA (DOLOR DE CABEZA)

MIGRAINE (HEADACHE) NO

3 MOLESTIAS GASTROINTESTINALES (DIARREA, DOLOR ABDOMINAL)

GASTROINTESTINAL NOISACES ( DIARREA, ABDOMINAL PAIN) NO

4 HIPOTENSION
HIPOTENSION NO

OBSERVACIONES DE LA AUTORIDAD SANITARIA

SANITARY AUTHORITY OBSERVATIONS

Declaro que los informes y respuestas dadas en la presente declaracion son exactos y
conforme a la verdad según mi leal saber y entender.
I declare that the answers and reports given at the present declaration are exactly and according to my
true acknowledge.

Firma y sello de Capitan.

Master Signed and Stamp
 AUTORIDAD MARÍTIMA DEL PERÚ
MARITIME AUTHORITY OF PERÚ
DIRECCIÓN GENERAL DE CAPITANÍAS Y GUARDACOSTAS
MARINA DE GUERRA DEL PERÚ Nº

INFORMACIÓN QUE DEBEN PRESENTAR LOS BUQUES A LOS QUE SE APLICA EL CAPITULO XI-2 DEL SOLAS 74 ENMENDADO, CON 72 HORAS DE ANTICIPACIÓN A SU INGRESO A AGUAS
DEL DOMINIO MARÍTIMO DEL PERÚ
Information that should be submitted by ships under chapter XI-2 SOLAS 74 Convention as amended, 72 hours prior to entering peruvian waters

1.- DATOS DEL BUQUE Y DETALLES DE CONTACTO (Particulars of the Ship and contact details)
1.1 Numero OMI / (IMO Number) 1.2 Nombre del Buque (Name of Ship) 1.3 Puerto de Matricula ( Port of Registry)

9358888 M/V "ANDINO" HAMBURG

1.4 Estado de Abanderamiento (Flag State) 1.5 Tipo de Buque (Type of ship) 1.6 Distintivo de Llamada (Call Sign)

GERMAN CAR CARRIER GFRH2

1.7 Números de Llamada INMARSAT (Inmarsat Call Numbers) 1.8 Arqueo Bruto (Gross Tonnage) 1.9 Nombre de la Compañía (Name of the Company)

764851613 40628 FHH FONDS NR.36 MS "MONZA" GmbH & Co. KG, Hamburg, Germany
1.10 Nombre y detalles de contacto de 24 Horas del Oficial de Protección de la compañía
( Name and 24-hour contact detail of the company Security Officer)

Mr. Bernd Rieper Emergency phone No.: +49 (0) 40 80 80 53 555

2.- INFORMACIÓN DEL PUERTO Y DE LA INSTALACIÓN PORTUARIA (Port and port facility information)
2.1 Puerto de Llegada 2.2 Instalación Portuaria donde atracara el buque si se conoce
(Port of Arrival) ( Port facility where the ship is to berth if known)

Callao
2.3 Fecha y Hora estimada de llegada a Puerto 2.4 Objetivo primario de la Escala
(Expected date and time of arrival of the ship in port) (Primary purpose of call)

27-01-2009 Discharge Cargoes ( Motor vehicles )

3.- INFORMACIÓN REQUERIDA POR LA REGLA XI-2/9.2.1 DEL SOLAS (Information required by SOLAS regulation XI-2/9.2.1)
3.1 El buque cuenta con (The Ship is provided with a valid) Si Yes No
- Certificado Internacional de Protección del Buque válido ( International Ship Security Certificate)

- Certificado Internacional Provisional de Protección del Buque válido ( Interim International Ship Security Certificate) X

3.2 El Certificado indicado en 3.1 ha sido emitido por

( The certificate indicated in 3.1 has been issued by)

Germanischer Lloyd
3.3 Fecha de Expiración ( Date of Expiry)
15-04-2009
3.4 Si el Buque no cuenta con un Certificado PBID válido o con un Certificado Provisional PBID válido, explicar el motivo
( If the Ship is not provided with a valid International Ship Security Certificate or a valid Interim International Ship Security Certificate, explain why?)

3.5 Tiene el Buque a bordo un plan aprobado de Protección del Buque (Does the ship have an approved ship security plan on board?) Si Yes No
X

3.6 Nivel de Protección Actual (Current Security level)

Security Level 1
3.7 Ubicación del Buque al momento del informe
(Location of the ship at the time the report is made) Lat.: 15-24.7 N Long.: 123-33.5 W

3.8 Enumere las 10 ultimas escalas en orden cronológico colocando en primer lugar la escala mas reciente en las instalaciones portuarias en las que el buque realizó interfaz buque puerto junto con el nivel de protección en el que opero el
buque

(List the last ten calls, in chronological order with the most recent call first. At port facilities at which the ship conducted ship port interface together with the security level at which the ship operated)

Fecha (Date) Puerto, País, Instalación Portuaria y UNLOCODE Nivel de Protección

Nº
De (From) A (To) ( Port, Country, Port Facility and UNLOCODE) (Security level)
1 26-12-2008 26-12-2008 SAN ANTONIO, CHILE (DAIKOKU PUBLIC) 1
2 23-12-2008 24-12-2008 IQUIQUE, CHILE (KINJO PIER) 1
3 21-12-2008 22-12-2008 CALLAO, PERU (HANMOKU PUBLIC) 1
4 27-11-2008 27-11-2008 YOKOHAMA, JAPAN 1
5 26-11-2008 26-11-2008 NAGOYA, JAPAN 1
6 24-11-2008 25-11-2008 YOKOHAMA, JAPAN (KINJO PIER) 1
7 18-10-2008 18-10-2008 SAN ANTONIO, CHILE (HANMOKU/DAIKOKU) 1
8 12-10-2008 13-10-2008 CALLAO, PERU 1
9 19-09-2008 20-09-2008 NAGOYA, JAPAN 1
10 0 0 , (HANMOKU/DAIKOKU) 1
3.9 Tomo el buque durante el periodo especificado 3.8 alguna medida de protección especial o adicional mas allá de las que se especifican en el plan aprobado de protección del Buque?
(Did the Ship during the period specified 3.8 take any special or additional security measures beyond those specified in the approved ship security plan?)

Si Yes No
X

3.10 Si la Respuesta a 3.9 es SI, por cada ocasión indíquese la medida especial o adicional que tomo el buque
(If the answer to 3.9 is YES for each of such occasions please indicate the special or additional security measures which were taken by the ship) N/A

Fecha (Date) Puerto, País, Instalación Portuaria y UNLOCODE Medidas de Protección Especial o Adicional
Nº
De (From) A (To) ( Port, Country, Port Facility and UNLOCODE) (Special or additional security measures)

3.11 Enumerese las actividades buque a buque en orden cronológico colocando en primer lugar la actividad buque a buque mas reciente que se haya llevado a cabo durante el periodo especificado en 3.8
(List the ship-to-ship activities in chronological order with the most recent ship-to-ship activity first. Which have been carried out during the period specified in 3.8)
No Aplicable (Not Aplicable) X

Fecha (Date) Ubicación o Latitud y Longitud Actividad Buque a Buque

Nº
De (From) A (To) (Location or Longitud and Latitud) (Ship To Ship Activity)

3.12 Se han mantenido procedimientos de protección al buque que se especifican en el plan aprobado de protección al buque, durante cada una de las actividades buque a buque que se especifican en 3.11
(Have the ship security procedures specified in the approved ship security plan, been maintained during each of the ship-to-ship activities specified in 3.11) N/A

Si Yes No

3.13 Si la respuesta a 3.12 es NO identifíquense las actividades buque a buque para las que no se mantuvieron los procedimientos de protección del buque e indíquese para cada una las medidas de protección que se aplicaron en su lugar

(If the answer to 3.12 is NO identify the Ship-to-Ship activities for which the ship security procedures were not maintained and indicate, for each, the secutiry measures which were applied in lieu)

Fecha (Date) Medidas de Protección Aplicadas Actividad Buque a Buque

Nº
De (From) A (To) (Security measures aplied) (Ship to ship activity)

3.14 Proporcionar una descripción general de la carga a bordo del buque

(Provide a general description of cargo aboard the ship)

Motor parts and vehicles

3.15 Transporta el buque alguna sustancia peligrosa como carga?
(Is the ship carrying any dangerous substances as cargo?) Si Yes No X

3.16 Si la respuesta a 3.15 es SI Proporciónese los detalles o adjúntese una copia del Manifiesto de Mercancías Peligrosas
(If the answer to 3.15 is YES, provide details or attach a copy of the Dangerous Goods Manifest) (IMO FAL Form 7)

3.17 Adjuntar una copia de la lista de la tripulación del Buque

( A Copy of the ships crew list (IMO FAL Form 5) Is attached)
3.18 Adjuntar una copia de la lista de Pasajeros
( A Copy of the ships Passenger List (IMO FAL Form 6) Is attached)
4.- OTRA INFORMACIÓN RELATIVA A LA PROTECCIÓN (Other Security-related information)
4.1 Hay Algún asunto relativo a la protección que quisiera informar?
(Is there any security related matter you wish to report?) Si Yes No X

4.2 Si la Respuesta a 4.1 es SI proporcione detalles

(If the answer to 4.1 is YES provide Details)

5.- AGENTE DEL BUQUE EN EL PUERTO DE LLEGADA DESEADO (Agent of the ship at the intended port of Arrival)
5.1 Nombre y detalles de contacto (Nº de Teléfono) del Agente del Buque en el Puerto de llegada deseado
(Name and contact details (telephone number) of the agent of the ship at the intended port of Arrival)

Wilmer Farias ( Line Chief - Agencias Universales Peru S.A.-AGUNSA ) Phone: 6190300 ext 1220

6.- IDENTIFICACIÓN DE LA PERSONA QUE BRINDA LA INFORMACIÓN (Identification of the person providing the information)
6.1 Nombre 6.2 Titulo o Posición 6.3 Firma
(Name) (Title of position) (Signature)

ANDRZEJ CHWIEDUK Master

Este Informe se realizó en:___________________________a______________________

This report is dated at ______Sea___________________on____03.Oct.2008 1420 R_________

(enter place) (enter time and date)

Esta información tendrá carácter de declaración jurada y ante cualquier omisión internacional o falta de presentación de este formulario. La Autoridad Marítima del Perú podrá considerarlo motivo fundado para
Adoptar medidas de control y cumplimiento previ

This Shall be an affidavit and any malicious omissions or the failure to submit this form could be considered by Maritime Authority of Perú sufficient ground to adopt control and compliance measures, under Rule
XI - 2/9 of SOLAS 74, Convention as amended
① Security Check List (for public berths) Nagoya Port Authority ETA：

No. Item
1 Name of Ship ANDINO
2 Nationality LIBERIA
3 IMO Number 9358888
4 Berth (pier) to be used W-
5 Security level(s) for the ship 1（One）
6 Security level(s) for the port facility 1（One）

No. Item No
7 Delivery of fresh water ✘

8 Delivery of fuel or lubricating oil ✘

9 Delivery of foods ✘

10 Delivery of ship's stores ✘

11 Repair works for the ship (engine, generators, cranes, boilers etc.) ✘

12 Lightening (cargo-handling between two ships) ✘

13 Crew change ✘

14 Others （　　　　　　　　　　　　　　　　　　　　　　　　　） ✘

No. Declaration of Security No

15 Request for DOS ✘

End
If the ship requests completion of a Declaration of Security, complete the following questionnaire, and sign at the bottom.
No. Reason(s) to request DOS
(1) The ship is operating at a higher security level than the port facility or another ship it is interfacing with.
(2) There is an agreement on a Declaration of Security between Contracting Governments covering certain international voyages or specific ships on those
voyages.

(3) There has been a security threat or a security incident involving the ship or involving the port facility, as applicable.

(4) The ship is at a port which is not required to have and implement an approved port facility security plan.

16 (5) The ship is conducting ship-to-ship activities with another ship not required to have and
implement an approved ship security plan.

If a ship requests completion of a DOS for any reason other than those listed above, it is asked to
provide good grounds for this request.

Port Facility　　　
No. Requirments to ensure security (NAGOYA)

17 Ensuring the performance of all security duties ✘

18 Monitoring restricted areas to ensure that only authorized personnel have access ✘

19 Controlling access to port facilities ✘

20 Controlling access to the ship

＊21 Monitoring of port facilities, including berthing areas and areas surrounding the ship ✘

22 Monitoring of the ship, including berthing areas and areas surrounding the ship
23 Handling of cargo ✘

24 Delivery of ship’s stores ✘

25 Handling unaccompanied baggage ✘

＊26 Controlling the embarkation of persons and their effects

27 Ensuring that a means of communication is readily available between the ship and port facility for security ✘

＊ There are limitations to monitoring of offshore side of the ship that can done by the port facility.
＊ The screening of the baggage belong to ship's personnel will be simplified at the port facility.
VHF Radio (ch.16) Nagoya Port Radio Contact (Ship)
T E L 81-52-398-0512 T E L
F A X 81-52-659-2066 F A X
E-mail [email protected] E-mail
The port facility and ship confirmed that the above security measures and responsibilities in 17 to 27 are
in place and being practiced.

Valid from until

Port Facility Security Officer Yasuo Marui Ship Security Officer

 Dated at Master
Job title Company
Name Company Security Officer

Signature of Port Facility Signature of SSO

 22.07.08

ANDINO
LIBERIA
9358888
W-
1（One）
1（One）

Yes

Yes

Fill out 16-27

aire, and sign at the bottom.

Check

ther than those listed above, it is asked to

Ship

the ship that can done by the port facility.

will be simplified at the port facility.
Contact (Ship)

y measures and responsibilities in 17 to 27 are

 IMO GENERAL DECLARATION

X Arrival Departure
1. Name and description of ship 2. Port of arrival 3. Date - time of arrival

M/V "ANDINO" YOKOHAMA, JAPAN 27-01-2009

4. Nationality of ship 5. Name of master 6. Port arrived from/Port of destination

GERMAN Capt. ANDRZEJ CHWIEDUK SAN ANTONIO, CHILE / NAGOYA, JAPAN

7. Certificate of registry (Port; date; number) 8. Name and address of ship's agent

HAMBURG, 20.11.2008, 21841

9. Gross Tonnage 10. Net Tonnage Agencias Universales S.A. - Chile
40, 628 14, 163 Address: Avda. Angamos 1546, Barrancas, P.O. Box 903,
11. Position of the ship in the port (berth or station) San Antonio, Chile

12. Brief particulars of voyage and subsequent ports of call; underline where remaining cargo will be discharged)

Yokohama, Japan

13. Brief description of the cargo

Motor Vehicles

14. Number of crew (incl. Master) 15. Number of passengers 16. Remarks

22 NIL
Attached documents

(indicate number of copies)

17. Cargo Declaration 18. Ship's Stores Decleration

1 1
19. Crew List 20. Passenger List 21. Date and signature by master, authorized agent or officer

1 NIL 27-01-2009
22. Crew's Effect Declaration* 23. Maritime Declaration of Health* Capt. ANDRZEJ CHWIEDUK
1 1
For official use

IMO FAL
Form 1

' '
( * ) Only on arrival