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 (MCU)
Review by
SEHAT/FIT * SEHAT DGN CATATAN/FIT WITH TIDAK SEHAT/UNFIT*
NOTE* …………………………………..
Hasil Covid 19 Test/ Covid 19 Test Result (Rapid Test)
REAKTIF/POSITIVE* NON REAKTIF/NEGATIVE*
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
Acknowledged by
Disetujui/Aproved

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