Power & Water Utility Company for Jubail Document ID No : MSSF-1-SF-043

and Yanbu (MARAFIQ) Page: 1 of 1

Rev. No.: 0
OHSMS FORMS
Date of issue: 10 Feb 2015

43. NOMINATION FORM FOR PTW AUTHORIZATION

Section 1: Nomination Details.

(Marafiq / O&M Dept Contractor manager shall complete this section and then submit to OHS Section.)
I would like to nominate
Mr.NABEEL ABDUL KAFFAR………………………. ID # 2448989414.............. Position …Mechanical…………
As AUTHORIZED PERMIT ISSUER / RECEIVER / CONTROLLER / GAS TESTER / WAI.
Marafiq facility / Area: (eg Power Generation/GTG, Water Production / RO etc..)

Section 2: Authorization Category & Discipline

1. Electrical: High Voltage Low Voltage Battery System UPS All works
2.Instrumentation&Control: Relay Room Control Panel Local Panel All works
3. Mechanical 3. Civil 4. HVAC 5. Fire Systems 6. Specify others
Section 3: Requestor: Marafiq Department / Contractor nominating authorized person –

Requested by: Name: Fahad Alhamad Signature: Position:

Project work title : (write in case of project contractor)

Marafiq Coordinating Dept Manager: Name …………………. Signature…………….

Section 4: PTW Written Test Result (To be completed by PTW Training Instructor )
Attempt Date % Marks obtained Passed/Failed PTW Training Instructor Sign
1st
2nd
Section 5: PTW Oral Test for API / APR / APC / AGT/WAI : Date of Oral Test:
Sl. # PTWA Committee Member Position % Marks Pass/ Fail Signature
1
2
3
Section 6: PTW Field Test for AGT (To be completed by PTW Committee member)
Date of Field Test % marks obtained Passed / Failed PTW Committee Name & Sign

Section 7:Issue of Authorization Card (To be completed by PTWA Committee chairman)

Authorization Card Number Date of Issue Validity Date Issued by Name & sign

OPRIETARY NOTICE IMPORTANT

THIS DOCUMENT CONTAINS INFORMATION PROPRIETARY TO MARAFIQ. ANY DISCLOSURE OR USE IS
EXPRESSLY PROHIBITED EXCEPT UPON WRITTEN PERMISSION BY MARAFIQ. Only document with stamps are considered official.