CSTS ID CARD REQUEST FORM

Please fill in column below

Name SUTRIS SETYO WIBOWO
Group BP / CSTS / Subcontractor / Visitor
Company PT. Meindo Elang Indah
User ID (filled by Security Admin)
Position Rebar
Blood type
Pick up point* Babo / Tofoi / Tanah Merah / Onar Baru / Sebyar / Rejosari / Kokas / Bintuni / Sorong
/ Fak-Fak / Java-Sorong-Babo
Origin* Expatriate / National / Papuan / Bintuni / Fak-Fak / IP
Emergency Number 081228080672
No KTP/Passport/KITAS 3301020309820004
Place of Birth Cilacap
Date of Birth 03-09-1982
Sex * Male / Female
Address Jl. Ahmad Yani

RT 02
RW 02
Kelurahan Planjan
Kecamatan Kesugihan
Kabupaten Cilacap
Provinsi Jawa Tengah
Postal Code 53274
Religion Islam
Marital Status Kawin
Nationality Indonesia
Education Senior High School
Other notes (if any)

*Choose one (circle)

Regards, Acknowledged by Site BM

SUTRIS SETYO WIBOWO ……………………………..

Attachment (soft copy):
- Copy of KTP/Passport and IMTA
- Photo (blue background)
- Copy of FFT
- Copy of MMR
 No. Form: FM-HRD-P01-02a
Rev.00 -tanggal: 28-11-2016

DATA PRIBADI PELAMAR

(PRIBADI DAN RAHASIA) PAS FOTO
3X4

JABATAN YANG DILAMAR :

IDENTITAS DIRI
1. NAMA LENGKAP : SUTRIS SETYO WIBOWO
2. TEMPAT / TGL. LAHIR : CILACAP, 03-09-1982
3. JENIS KELAMIN :L/P*
4. STATUS : KAWIN / CERAI / BELUM KAWIN *
5. AGAMA : ISLAM
6. KEWARGANEGARAAN : INDONESIA
7. NO. KTP (DKI/DAERAH) : 3301020309820004
8. NO SIM (A/B/C)* :
9. ALAMAT LENGKAP : PLANJAN RT. 02 RW. 02
KESUGIHAN, CILACAP
Kode Pos : 53274
10. NO. TELEPON : HP : 081228080672
11. E-MAIL : yanithalita78@gmail.com
12. STATUS TEMPAT TINGGAL : SEWA / KONTRAK / IKUT ORANG TUA / IKUT WALI *
13. HOBBY : MANCING

RIWAYAT PENDIDIKAN
1. PENDIDIKAN FORMAL
TAHUN
TINGKAT NAMA SEKOLAH JURUSAN
DARI SAMPAI
SD SD NEGERI DONDONG 02 1990 1996

SLTP SMPN 1 KESUGIHAN 1996 1999

SLTA
AKADEMI
UNIVERSITAS
S2 / S3 *

2. KURSUS / SEMINAR
(YANG BERHUBUNGAN DENGAN PEKERJAAN)

TEMA PENYELENGGARA WAKTU

1.
2.

*
CORET YANG TIDAK PERLU HAL 1 DARI 5
 No. Form: FM-HRD-P01-02a
Rev.00 -tanggal: 28-11-2016

3.
4.

3. PENGUASAAN BAHASA

MACAM BAHASA MENDENGAR BERBICARA MEMBACA MENULIS

1. INDONESIA BS BS BS BS
2.
3.
4.
BS = BAIK SEKALI B = BAIK C = CUKUP K = KURANG

4. RIWAYAT PEKERJAAN
(5 TAHUN TERAKHIR)

MASA WAKTU NAMA PERUSAHAAN JENIS USAHA JABATAN

1. 10 Juni 2016 PT. Timas Suplindo Rebar Helper
2. 5 Agustus 2014 PT. Hans Jaya Utama Rebar Helper
3. 10 Januari 2011 PT. Inwha Indonesia Rebar Helper
4. 10 September 2006 PT. Tiksuri Rebar Helper

5. ALASAN BERHENTI DARI PEKERJAAN TERAKHIR

6. GAJI TERAKHIR YANG DITERIMA:

7. FASILITAS TERAKHIR YANG DITERIMA

LATAR BELAKANG KELUARGA

1. NAMA & ALAMAT ORANG TUA

NAMA UMUR PEKERJAAN KETERANGAN

AYAH : Alm. Sanaris - - -
IBU : Alm. Sanikem - - -
ALAMAT ORANG TUA :

TELEPON :

*
CORET YANG TIDAK PERLU HAL 2 DARI 5
 No. Form: FM-HRD-P01-02a
Rev.00 -tanggal: 28-11-2016

2. NAMA-NAMA SAUDARA

NO NAMA UMUR PEKERJAAN KETERANGAN

1 PARNO 38 BURUH
2 SLAMET 42 BURUH
3
4
5

3. NAMA & PEKERJAAN SUAMI / ISTRI * PELAMAR

NAMA SUAMI / ISTRI * UMUR PEKERJAAN KETERANGAN

DWI SETIYANI 29 BURUH
ALAMAT :

TELEPON :

4. NAMA-NAMA ANAK PELAMAR

NO NAMA UMUR PEKERJAAN KETERANGAN

1 THALITA 7,5 TH
2
3
4
5

ORGANISASI YANG PERNAH / SEKARANG DIIKUTI

NAMA ORGANISASI JABATAN PERIODE

1.
2.
3.
4.

KONDISI KERJA YANG DIHARAPKAN

1. GAJI MINIMUM UMR

2. FASILITAS LAIN
3. BERSEDIA BEKERJA DENGAN SISTEM KONTRAK YA / TIDAK *
4. BERSEDIA MENJALANI MASA PERCOBAAN 3 BULAN YA / TIDAK *
5. BERSEDIA DITEMPATKAN DILUAR P. JAWA YA / TIDAK *

*
CORET YANG TIDAK PERLU HAL 3 DARI 5
 No. Form: FM-HRD-P01-02a
Rev.00 -tanggal: 28-11-2016

KESEHATAN
1. PENYAKIT BERAT YANG PERNAH DIDERITA

JENIS PENYAKIT TAHUN LAMANYA KETERANGAN

1.
2.
3.

1. KECELAKAAN BERAT YANG PERNAH DIALAMI

PERNAH MENGALAMI KECELAKAAN BERAT PADA TAHUN:

AKIBAT DARI KECELAKAAN TERSEBUT:

REFERENSI
1. SEBUTKAN NAMA TEMAN / KENALAN (YANG TIDAK ADA HUBUNGAN SAUDARA) YANG
DAPAT MEMBERIKAN KETERANGAN TENTANG DIRI SAUDARA (3 ORANG)

NAMA ALAMAT NO. TELPON

1.
2.
3.
4.

DEMIKIAN DATA PRIBADI PELAMAR INI SAYA ISI SESUAI DENGAN KEADAAN SEBENARNYA. JIKA
DI KEMUDIAN HARI TERNYATA SAYA MEMBERIKAN KETERANGAN PALSU, MAKA SAYA
BERSEDIA DIKENAKAN SANKSI SESUAI DENGAN PERATURAN YANG BERLAKU.

CILACAP 14 AGUSTUS 2019

_______,_____________

PELAMAR

SUTRIS SETYO WIBOWO

_______________________

*
CORET YANG TIDAK PERLU HAL 4 DARI 5
 No. Form: FM-HRD-P01-02a
Rev.00 -tanggal: 28-11-2016

Gambarkan Struktur Organisasi (minimal 2 perusahaan) terakhir dan perlihatkan posisi Anda pada Struktur
Organisasi tersebut.

Nama Perusahaan:

Nama Perusahaan:

*
CORET YANG TIDAK PERLU HAL 5 DARI 5
 SITE ID APPLICATION AND ISSUANCE FORM
(For WHITE, BLACK and VANTAGE ID) R-5: ... May 15

This form is to be completed for anyone who: 1) would like to visit Tangguh for the first time, 2) change on personnal information
3) missing ID or replace ID badges, 4) Change company/ employer.

Instruction
1. Applicant to complete section 1, Leaders to complete section 2, Issuing Authorities to complete section 3
2. CIRCLE all options applicable each question, Write in CAPITAL for any questions.
3. Aplicant to collect applied ID from the Issuing Authorities with required supporting document at TLNG site.
Note: Failure to complete accurate information may delay authorisation and the card issuance

Section 1: to be completed by Applicant

Personal data:
Name as written in Passport or KTP
S U T R I S S E T Y O W I B O W O
Place of Birth Date of birth (dd/mm/yy) Sex Nationality Blood type Rh
C I L A C A P 0 8 0 9 8 2 M F I N D O N E S I A A AB B O + -
Current Home Address
JL. AHMAD YANI RT. 02 RW. 02 PLANJAN KESUGIHAN

Post Code
Home Phone Mobile Phone Other Phone Email Address
081228080672
Passport/ KTP No. Expired date (dd/mm/yy)

For Expatriate Only

Visa Type Visa Expired Date (dd/mm/yy) SKJ Expired Date (dd/mm/yy) IMTA Expired Date (dd/mm/yy)

Place of Hiring Jakarta Overseas, Country:

Bird Head Bintuni Fak-fak Manokwari Sorong Babo Arandai Kokas
DAV Tofoi Tanah Merah Saengga Onar Tomage Otoweri Weriagar Tomu Taroy
City:Rest of Papua
Emergency Contact Details First (primary) Secondary Thirt options
Surename DWI SETIYANI
Middle name
Given / First name
Title (e.g. Mr/ Mrs)
Relationship WIFE
Is this your next of kin?
Day Phone
Night Phone
Mobile Phone 081364370027
Address (only if different
with your home address)

Post Code
Applicant's Contact Person at Tangguh Site: Phone Company
Name
Applicant's Contact Person at Home Office: Phone Company
Name
Employers/ Company Address

Have you ever entered Tangguh LNG Site before? Y N

If Yes, When was your last visit (mm/yy) What was your vantage ID

What company did you work for

I confirm that I have: 1) submitted my medical data to BP Doctor, 2) attached copy of valid KTP/ SIM/ Passport
By signing this form I declare that the above information is accurate. I agree to report missing ID and return these ID card to Security
Department at the last day of my presence at Site.
Applicant:

Name : SUTRIS S.W. Date:

Section 2: to be filled in by Employer/ Leader/ Visit Host

Positon/ Job Title of applicant Company/ Employer

Status BP Staff BP Direct Contract TPC/ Contractor. Visitor/ Non Workforce VIP Apprentice
For Contractor/ Visitor: Validity of contract, From (dd/mm/yy) Until (dd/mm/yy)

Duration of this visit: Walk On <15 days > 15 days Date of arrival to site:
Work status at Site Rotation Visit <6 times per year Visit >6 times per year
Plan Work Location Babo Site LNG Site Villages Other:
Site Office base, (if applicable) Others: Site Phone number NA
Babo Office Admin Bldg Central Bldg Clinic Fire Station Marine Bldg Security Bldg Warehouse A
MCB/ Plant Marine vessel BP Workshop BP MT Shop Matoa Office Stinkul Office Shorebase

Does Applicant required to work inside IT&S Facilities? Y N If Yes, please contact x4554 to fill IT&S Permit form.
Does Applicant required to work inside Process Plant Area? Y N
Does Applicant required to work at NUI/ Offshore Platform? Y N
If Yes, explain why

I confirm that the applicant is needed to visit site, information provided are accurate and have met all requirements.
For contractor personnel to be approved by both parties. Approved by
Aprroved by BP Line Manager/ Site Visit Host
Contractor Manager/ Site Visit Host

Name : Date: Name: Date:

Section 3: to be completed by HSE Trainer

I confirm that the Applicant has attended appplicable induction training as per application form.
Trainer
WHITE ID induction Y N
BLACK ID induction Y N
Name: Date:

Section 4: to be completed by ID Issuance Authorities

Requirement to issue Vantage ID I confirm that data has been entered accurately and no double ID
1. Medical Certificate from BP Doctor Vantage Coordinator

Vantage ID Number Name: Date:

Requirement to issue Temporary & Permanent WHITE ID and BLACK ID

1. Copy of valid SIM/ KTP/Passport I confirm all requirement have been met and data base updated
2. Section 3 signed off Security Coordinator
3. Work Rota or Visit>6/year, duration > 15 days (for permanent)
BLACK ID Number
White ID Number Name: Date: