Form Permohonan Kerja Subcon

Form Subcon Job Application

REV : 0 / 200722 FM – HES – 20

PT GEM Contractor Visitor/Vendor

Hari, Tanggal/ Day,
Date : Perusahaan/ Company Pimpinan Perusahaan/ Company
Alamat Kantor/ Address Reps. (PIC)

Telp Kantor/ Office Phone Email

Kantor/ Office Email
Nama PIC Perusahaan di Site / PIC
Reps on Site
Name :

Nama Karyawan/ Employee Name Pemohon/ Employee

Jabatan/ Position

Alamat/ Address

No Telp / HP
Mulai Bekerja/ Start Working
Akhir Bekerja/ End Contract Name :

Lampiran/ Attachment
1. Kartu Identitas / KTP Ada Tidak
2. MCU/ Medical Check Up Ada Tidak
3. Hasil Covid 19 Test/ Covid 19 Test Result (Rapid Test) Ada Tidak
4. Health Questionnaire Covid 19 Ada Tidak
8. BPJS Ketenagakerjaan/ Employee Insurance Ada Tidak
9. Sertifikat sesuai Job/ Certificate as per job (Operator, SHE, Scaffolder, TKBT-2, CSE) Ada Tidak
10. Foto Karyawan dengan background warna biru muda/ Photo Employee Ada Tidak
Hasil MCU dan Covid 19 Test/ MCU and Covid 19 Test Result (Diisi oleh Bagian HSE)
Hasil Pemeriksaan Kesehatan/ Medical Examination (MCUJ
Review by
SEHAT/F/7* SEHAT DGN CATATAN/F/T \/I//TH TIDAK SEHAT/U/VFIT’
NOTE* .........................................
Hasil Covid 19 Test/ Covid 19 Test Result (Rapid TestJ
REAKTIF/POSITIVE* NON REAKTIF//VEGA 7/yE*
HR-GA Dept
’Penilaian berdasarkan hasil MCU dan Covid 19 Test/ Refer to MCU and Covid 19 Test Result Name :
Safety Induction/ Orientasi K3 (Diisi oleh SHE GEM)
Pelaksanaan Safety Induction/ Safety Induction
Hari, Tanggal, Jam/
Day, Date, Time

GEM Trainer/ Reps.

Name :
Rekomendasi/ Recommendation
Disetujui/Aproved Acknowledged by

Tidak disetujui/ Unaproved

Catatan/ Note : HSE Manager/ Reps.
Name :

Persetujuan/ Approval
Note : Approved by Approved by

Representative / User HR-GA

Name : Name :

COPY :
Security HSE Dept HR-GA Dept Requester/ Employee