OIL & NATURAL GAS CORPORATION

LIMITED
MUMBAI REGION
REGIONAL SECUIRITY HQRS
1ST Floor, Vasudhara Bhavan, Bandra (E),Mumbai 400 051.
Tele Fax No : 022 2699692

Non-Employee Duty Pass Application Form

To be filled in duplicate, by the individual and submitted to the DGM (Security) through Principal
Employer. (Application should accompany Approval of ONGC`s contract executing department, proof of Date of
birth, Nationality, mandatory safety training certificates, current Police clearance certificate and two latest
passport size color photographs).
FIRST
SYARLI

1. Name in full
(In block letters)

MIDDLE

SURNAME
WELLMAN

PHOTOGRAPH

2. Father`s Name

: SYAHRIL SAHAR

3. Date of Birth (DD:MM:YYYY)

: 19-06-1979

4. Place of Birth

: DURI

5. Nationality

: INDONESIAN

6. Blood Group

: O+

7. Designation

: QC INSPECTOR

8. Qualification

: CSWIP 3.1 WELDING INSPECTOR

9. Contractor`s Name

: SWIBER OFFSHORE CONSTRUCTION PTE.LTD

10. Contract No. and Date

11. a) C&A Verification :i) Date__________________(ii) Issued by___ _________________

b)MHA (for expatriates only) (i) Date of Application _____________________________
12. Residential Address :No.

Details

Present Address

Permanent Address

a)

Flat / Room No.

SWIBER OFFSHORE INDIA

(PVT.) LTD.

Perum. Telaga Sakinah

b)

Building Name / No.

502-B WING, DELPHI

Block CD 19/4

c)

Street Name

HIRANANDANI GARDENS

Jl. Walisongo III

d)

Location / Area / Village

POWAI

Cikarang Barat

e)

Police Station

POWAI

Cikarang Barat

f)

City

MUMBAI

Cikarang

g)

District

MUMBAI

BEKASI

h)

State

MAHARASHTRA

Indonesia

i)

Pin Code

400 0076

j)

Tel. No.

k)

E-Mail ID

+6282172300419
Syarli.wellman@swiber.com

Syarli.wellman@swiber.com

13. Name & Tel. No. of text Kin

: RINI YULISTANTI, +6282170261959

14. Visible Identification Marks

: Have beard

15. Passport Details:

a) Passport No.
b) Issued by
c) Valid up to

: A 7337278
: REPUBLIC OF INDONESIA
: 22 JAN 2019

16. Type of Visa: _______________ Valid up to ___________

(Only Business & Employee Visas are allowed)
17. Details of Mandatory Safety Course undergone viz:
a) Survival at sea
Date of issue: 14 MARCH 2012
b) Fire Fighting training
Date of issue: 14 MARCH 2012
c) First Aid
Date of issue: 14 MARCH 2012
d) HUET
Date of issue: 14 MARCH 2012
18. Required Work Location: ___ _ONGC MUMBAI HIGH OFFSHORE FIELD _________________
19. DECLARATION: I hereby declare that the particulars given above are correct to the best of my
knowledge and belief. I further declare that my pass issued by ONGC security section will be
surrendered to the security section through the principal contractor immediately on completion of
its validity period/completion of contract, whichever is earlier. In case of loss of pass, I will
immediately report the matter to the police and produce the FIR in original to security section.

___________________________
Countersigned by the contractor
(Office seal with Name & Designation)

_________________________________
Signature of contract workmen

20. DECLARATION: Attached supporting documents have been scrutinized. He has undergone the
mandatory offshore safety trainings. Certified for issue of NED Passes. The photocopies of all
documents are attested by company representative and they were compared with original by me.
After comparison, the original certificates are returned and attested copies are enclosed herewith
along with Moha Clearance copy.

Date: ___________________

Countersigned by Project In Charge of ONGC

(With office seal)
__________________________________________________________________________________________
OFFICE USE
Pass No.: ______________________
Issue Date: ______________________ Valid up to: _______________________
Signature of CIC

Specimen Signatures: