Form 22

IMMIGRATION ACT
(CHAPTER 133)

IMMIGRATION REGULATIONS
CREW LIST

Name of Vessel / Nama Kapal MATSUMAE test

Gross Tonage / GT Kapal 9,998.00 MT test
Agent in Port / Keagenan PT.HUA Bahodo test
Owner's / Pemilik johanna interntest
Date Of Arrival / Tanggal Tiba : Oct-2024 Last Port / Pelabuhan Sebelumnya GLADSTONE-AUSTRALIA
Date Of Departure / Tanggal Berangkat : Oct-2024 Next Port / Pelabuhan Selanjutnya JIANG YIN,CHINA

No. Name / Nama Awak Sex / Date of Birth / Nationality / Travel Document No. / Doc.Of Travel Expired / Duties on Board / Seaferer Code / No. PKL
Jenis Kelamin Tanggal Lahir Kebangsaan Seaman's book number Seaman's book exp date Jabatan Kode Pelaut
1 NGUYEN CONG KIEN M 21-Nov-1982 VN HPG-13974 UNLIMITED MASTER
2 TRAN DUC HOANG M 29-Dec-1985 VN HPG-07669 UNLIMITED C/O
3 PHAM DINH SON M 15-Feb-1993 VN VN002665-01 UNLIMITED 2/O
4 PHAM THE TAI M 6-Sep-1987 VN HPG-10202 UNLIMITED 3/O
5 DO THANH TUNG M 9-Aug-1982 VN VN016102-01 UNLIMITED C/E
6 HOANG VAN THUC M 3-May-1984 VN HCM-03849 UNLIMITED 1/E
7 NGUYEN QUOC HUY M 6-Feb-1991 VN VN000498-01 UNLIMITED 2/E
8 PHAM VAN VI M 1-Feb-1991 VN HPG-32244 UNLIMITED 3/E
9 MONDRAGON,ARTURO PADRONES M 8-Oct-1967 PH C1551937 21-Oct-2029 BSN
10 HA VAN HUNG M 17-Jun-1982 VN HCM-12725-01 UNLIMITED AB-A
11 HO QUOC HOA M 28-Apr-1998 VN VN016653-01 UNLIMITED AB-B
12 VU DUC TOAN M 12-Aug-1997 VN VN024383-01 UNLIMITED AB-C
13 TRAN QUYET THANG M 13-Sep-2001 VN VN035707-01 UNLIMITED O/S-A
14 NGUYEN VAN KHIEM M 3-Jan-1999 VN VN018946-01 UNLIMITED O/S-B
15 CABIGAO,GLADWIN CAMACHO M 6-May-1991 PH C1053917 5-May-2028 OS-C
16 NGUYEN QUOC HUY M 7-Jan-1997 VN VN010762-01 UNLIMITED OLR-A
17 VU DUY DUNG M 8-Nov-2000 VN VN018982-01 UNLIMITED OLR-B
18 PHAM VAN TRUONG M 10-May-1992 VN VN013010-01 UNLIMITED OLR-C
19 VU NGHIA NHAN M 17-Aug-1982 VN VN007403-01 UNLIMITED C/CK
20 PHAM THUAN HOAN M 30-Dec-1988 VN VN009808-01 UNLIMITED M.M
Person included master.

Note :
1. Flag status means the sign on/off crew after Bahodopo port, if the crew planned to sign off after Bahodopi port, pls fill "Turun", if the crew planned to stay on the vessel after Bahodopi port, pls fill "Naik"
2. Y means Ya/Tes, T means Tidak/No, for Master table, pls only fill Y in the master's position, for others pls fill as T
3. For the vaccination status, if crew already being vaccinated pls fill Y, if not then pls fill T
 Date of Sign On / Certificate / Certificate No. / Passport No. / NIK Passport Expired Date / Flag Master Y/T Vaccination Port Sign On
Tanggal Sign On Sertifikat Ijazah Pelaut No. Sertifikat Ijazah Pelaut No. Passport Tanggal Berakhir Passport Status
10-Apr-2024 G2394.MT1 G2394.MT1 C3548631 22-Jun-2027 Naik Y Y ULSAN
28-Mar-2024 G2458.CO1-02 G2458.CO1-02 E01170439 27-Nov-2033 Naik T Y OSAKA
6-Sep-2024 A3839.CO1-01 A3839.CO1-01 C2123501 4-Aug-2026 Naik T Y MASAN
28-Mar-2024 G8184.DO1 G8184.DO1 C9381856 23-Nov-2030 Naik T Y OSAKA
6-Sep-2024 G2124.CE1-03 G2124.CE1-03 C5671877 18-Jul-2028 Naik T Y MASAN
6-Sep-2024 A3007.SE1 A3007.SE1 C9387668 8-Oct-2030 Naik T Y MASAN
6-Sep-2024 G6239.EO1 G6239.EO1 E01903334 20-May-2034 Naik T Y MASAN
28-Mar-2024 A8035.EO1 A8035.EO1 E01255663 6-Jan-2034 Naik T Y OSAKA
28-Mar-2024 P4572432B 26-Jan-2030 Naik T Y OSAKA
6-Sep-2024 G1039.ABD-03 G1039.ABD-03 C9914581 14-Dec-2031 Naik T Y MASAN
6-Sep-2024 A16659.ABD-01 A16659.ABD-01 C9320605 10-Sep-2030 Naik T Y MASAN
28-Mar-2024 A17046.ABD-01 A17046.ABD-01 K0212356 1-Apr-2032 Naik T Y OSAKA
6-Sep-2024 A19768.OSD A19768.OSD P00415765 17-Aug-2032 Naik T Y MASAN
6-Sep-2024 A14547.ABD A14547.ABD C9121298 8-Jun-2030 Naik T Y MASAN
28-Mar-2024 P0063160C 12-May-2032 Naik T Y OSAKA
28-Mar-2024 A9396.ABE A9396.ABE C5998828 31-Aug-2028 Naik T Y OSAKA
6-Sep-2024 A17721.OSE A17721.OSE P02654571 13-Sep-2033 Naik T Y MASAN
28-Mar-2024 A13430.ABE A13430.ABE C6999314 22-Mar-2029 Naik T Y OSAKA
28-Mar-2024 VMUC 000424D VMUC 000424D C4353713 11-Jan-2028 Naik T Y OSAKA
6-Sep-2024 VMUC000541D VMUC000541D C5444977 15-Jun-2028 Naik T Y MASAN

hodopi port, pls fill "Naik"

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