Information Required For Safety Clearance For Releasing Bill Date :

Name Of The Agency :

Billing Period :
Po No :
Period Of Work :

Sample
Number/
Sl No. Parameters photos to
Date
attached
Nominated Safety Supervisor/ Personel, Y/N (Required if Manpower > 50
If Yes ;
1 Name :
Mobile No:-
Number of Site Safety Visits during billing period
2 ( Period From to )
(Weekly Once,Date & Sample Photo)
Number of Pep TALKS conducted
3
(Weekly Once,Date & Sample Photo)
4 Number Of incidents (Reportable/First AID) reported to safety till date
5 Reporting of Near miss cases to safety till date (Minimum One in a 3 months)
Amount Of Penalties imposed to the Agency against safety violations if any
6
(Reference Number)

Declaration :
The work has been executed without any safety violation.
The above information are true and correct to the best of my knowledge.

Sign Of EIC Sign Of the Agency