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Form Rev 0

CREW PARTICULARS
Vessel Name Position
AB

CREW’S PARTICULARS Photographs


Name Contact No
WALTER EDEWAN +6281364541674

Address / Overseas
Perumahan Taman Sari Hijau, Blok G7 No. 16 Tiban – Batam – Indonesia

NRIC / Passport Date Of Birth Citizenship


U 594236 24/02/1977 Dumai, Indonesia

Age Race Religion


33 Years old Malayu MOSLEM
Marital Status Name of Spouse (If any) No of Children (If any)
One
Single / Married / Divorced

NEXT OF KIN’S PARTICULARS (


Name Relation Contact No
TURINO FATHER +6281371194668

Present Address (If different from above)


Jl. Hayam Wuruk, GG Firdaus No. 267 Dumai - Indonesia

NEAREST AIRPORT : Hang Nadim BATAM


TIME REQUIRED TO REACH AIRPORT : 1 Hour

DECLARATION
Have you ever been convicted of any criminal offence? Yes / No
Have you ever file for bankruptcy? Yes / No
Have you been hospitalized for more than 6 months? Yes / No
Have you ever been dismissed/suspended by other organization? Yes / No

I hereby certify that the above information is true to the best of my knowledge
and that I have not willfully suppressed any material facts

WALTER EDEWAN / 07 July 2010


Signature of Crew / Date

FOR OFFICE USE


Salary Commence Date Verified By

FOR OFFICE USE


Date Joined Coverall Size Safety Shoe Size
L 40