PRIMA NIRBHAYA MSE 2.

03
Form

HEALTH, SAFETY, ENVIRONMENT & SECURITY SYSTEM DEPT.

ID SERVICES REQUEST
The level of urgency/tingkat urgensi/ tingkat urgensi : Very Urgent As normal scheduled
Pls describe justification if you raise a very urgent request.

Proposed by/Diajukan oleh:

Contractor name/Nama kontraktor

Nominees Details Fulfilled by HSEs Dept

Keterangan Peserta Dilengkapi oleh HSES Dept

NAME DATE OF BIRTH POSITION*

TRAINING REQUIRED Schedule
Training yang diperlukan ( ) Jadual Pelatian
NO
Nama Tanggal Lahir Posisi HSE EPD ** Radio #
Induction Induction Comm
General HSE Induction

Expansion Project

Radio Communication

Fulfilled by HR Divsion
Dilengkapi oleh HR

Verify the expartrates

documents

RPTKA

KITAS & Copy passport

IMTA

Recommendation ESDM

Organization Chart

Curriculum Vitae
Verified by

Name & B/N

*) Position title of nominees/Nama posisi orang yang akan menghadiri pelatihan

**) Required for those who will perform a job in pit areas/Dibutuhkan bagi mereke yg akan bekerja di area tambang
#) For those nominees who use a two way radio devices in pit areas/Dibutuhkan oleh mereka yang mengunakan radio
komunikasi di areal tambang

Note : 1. KPC user signature applied for labor supplier nominee only/ tanda tangan dept pengguna berlaku hanya untuk labor supplier
2. Please attach Medical Certificate & Copy ID Card/Lampirkan hasil medical setiap peserta & copy KTP
3. For expatriate nominee only: must attach the copy RPTKA, KITAS&passport, IMTA, Recommended of ESDM, Organizaton Chart, and CV of Nominee

Approved by/Disetujui oleh: Acknowledged by/Diketahui oleh:

Contractor Manager Custodian Manager/KPC User (Penanggung Jawab)

Name & BN: Name & BN:

Position: Position:

Document Title Approved By Effective Date Uncontrolled Document

ID Services Request Form / Formulir Pengajuan ID Kerja GM HSES 01 Nov 2012 When Printed or Out of HSE Info

Doc Registration No. Version Next Review Due

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HSE_KPC_KPC_MSE2.03_DOC_FRMb_001 2.1 01 Nov 2017