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Format No.

: 01
Rev. No. :02
Page 1 of 1

Special Privileges Request Form (For USB Access)

1 Name

2 P S No.

3 Department / Project.

4 Machine Name
5 Duration From Date /Time
6
Date /Time
Duration Up to

7 Purpose

I assure that the privilege(s) given to me shall be used only for business activities and will be abide by
the confidentiality agreement made with the company.

Signature of Requester
Name:
Department:
Mobile No:

As per the business need I authorize the concern for the special privileges for the mentioned period.

Signature of HOD/ PM

Name / P S No. :

Signature of HOD – IT

Prepared By: ISD Verified by: Project Manager

This document contains information which is confidential and proprietary to L&T Construction Transportation
Infrastructure. It shall not be reproduced in whole or in part or released to any third party without the prior
written consent of L&T Construction Transportation Infrastructure.

FORMAT NO. 01 REV. NO. 02 DATE 06DEC2018

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