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HSE Guidelines – Offshore Safety Passport MY ALL S 08 007

Rev 3 August 2007


__________________________________________________________________________________

PETRONAS CARIGALI OF FSHORE SAFET Y P ASSPOR T APPLICA TION FORM

Type of Employee: Carigali Contractor Category Applied A B C D Visitor


New Renewal Replacement
Full Name:
Name (to print): D.O.B. Sex: M F
Staff/IC/Passport No. Race:
Nationality: Religion
Blood Group: Allergies:
BUSINESS Main Contractor Sub-Contractor Contract Expiry:
Position Title:
Employer:

Address:

Phone No: Fax:


NEXT–OF–KIN PARTICULARS
Name:

Address:

Relationship: Phone no:


MEDICAL FITNESS ASSESSMENT
AME No:
AME Name:
Date Examined: Expiry Blood Type:
OFFSFHORE SAFETY & SKILL TRAINING
Combined Offshore Safety Training: Y N Valid Till:
Helicopter Underwater Escape: Y N Valid Till:
Certificate No:
Skill Training 1
Skill Training 2
Skill Training 3

Signature of Sponsoring Dept, PCSB &


Signature of Applicant Signature of Applicant Manager & Stamp
Stamp
Name: Name:

FOR HSE DEPT. USE ONLY


Application Reviewed by: Date:
Passport Type: A B C D Visitor Valid Until:
Issued by:
Signed:
Date Issued:

Please enclose: i) recent passport-sized colored photograph


ii) photocopy of IC or International Passport (for contractors)
iii) original and photocopy of training and medical certificates

PETRONAS CARIGALI SDN BHD Section 3


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