? REQUEST FORM G.I.

P AND BADGING
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CONTRACTOR NAME : CV. IKB

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CONTRACT NUMBER : STM-CN22-O17-C
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F CONTRACT DESCRIPTION : DRIL SITE CORPORATION
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REQUEST DATE : 16-06-2022
v. CONTRACT DURATION START DATE . 30 Mei 2022
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DATE '
o EXpiRy 29 Mei 2022
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REMARK (SEE NOTE)

NAME
NO, BADGE POSITION
(Print Full Name) Previous
(1) (2) (3)
Baqde
1 Warvan Kumiarvan Helper Person I okal Hir'u
2 Baharudin Helper Person Lokal Hu'u
3 Abubakar Ass. Logistik Person Lokal Hu'u
4 David Ramadhan Helper Person Lokal Hu'u
5 Hermansyah Helper Person Lokal Hu'u
6 Burhanudin Helper Person Lokal Hu'u
B
F 7 Hidayat Helper Person Lokal Hu'u
U
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o- 8 Rizkillah Person Lokal Hu'u
E Listrik
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U 9 Muhdar Itlason Person Lokal Hu'u
O A'an Ansari Setiawan
F 10 Proiect [.4anaqer Persolr Lokal Hu'u
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Summary of total manpower to date

Originalcontract :

Additional (Last request) : 13

Additional (This request) : 10

a,
Total to date :

-lustification i

Note :
Please mark
1) Subcontractor : Name of Subcontractor which supply the person
2) Direct Hire Local : Local District (Hu'u, Dompu, Bima)
3) Direct Hire Outsider : Non Local as item 2 above
The contractor shall provide justification when request GIP/Badging for Manpolver replacement
and shall attach Contract Instruction or Contract Variation for each badging/GlP request.

THE MUST
copy person yoLr
2. Submit the form as attached (Attachment 1 - Manpower Information Data) - for new employee
3, ,Attached Copy of Medical Fit Certificate issued by valid institution
Contractor should subnrit REQUEST FORlvl of GIp AND BADGING, at least 6-working-davs
to GIP conducted

Approved by: Approved by: Approved by:

nB lcpj Contract Owner Safety Dept

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SUMBAWATIML}E MINING

ATTACHMENT 1
M AN POWER D ATA I N FORM ATI ON

Photo

No. badge

Contractor Name
Full Name / Nama Lengkap \..f lnr rar. I /, .-.r'.2r..!a^
Address I Alamat
=aufo-
Local / Non Local (
-ml
Home Phone / Mobile / No. HP
State I Bangsa

Place/Date of Birth ( D.O.H ) / T.T. Lahir DO L' -a1 -2ooo

Date of Hire / Tanggal Diterima U? oc
Point of Hire (POH)/ Tempat Diterima

Marital Status / Status Pernikahan furu"n tn

Gender ( L/P ) L
lD Number / No KTP q2ora34 t 6100068(
Position / Posisi

Departement

Education / Pendidikan tua

Emergency Contact

Other lnformation

Proposed By, Approved By,

Contract Owner
Name : Name :
B/N : B/N :
 ?
$UMEAWATIMUR MINIhIG

ATTACHMENT 1
M AN POWER D ATA I N FORM ATI O N
Photo

No. badge

Contractor Name L\f, 1\-

Full Name / Nama Lengkap __9_er_ A
pils 1|-r
Address / AIamat \-tr-i tu
Local I Non Local LOCa;
Home Phone / Mobile I No. HP
State / Bangsa _! _N iY_#_a-
(__ -qq -_ _ __ __

Place/Date of Birth ( D.O.H ) / T.T. Lahir 'Ll - I ,-

Date of Hire / Tanggal Diterima Z Lazl-
Point of Hire (POH)l Tempat Diterima

Marital Status / Status Pernikahan : {Saturu i.Z-r"a\,a}tlrz

Gender ( LiP ) L
lD Number / No KTP .rzc) saSt t402 n.a oool
Position / Posisi 1(@?€k
Depadement
Education / Pendidikan SOa.+
Emergency Contact

Other lnformation

\_

Proposed By, Approved By,

Contract Owner
Name : Name :
BIN : B/N :
 ?
ATTACHMENT 1
M AN POWER D AT A I N FORMATIO N

Photo

No. badge

Contractor Name C-V,

Full Name I Nama Lengkap AgU bAkArL

Address / Alamat Va*>bou
Local / Non Local LocAl
Home Phone / Mobile / No. HP : 0?S 3V1 \VC un--l
State / Bangsa lntonaWc',
Place/Date of Birth ( D.O.H ) 1T.T. Lahir Dow?o , I L-a ^Wo
L Date of Hire / Tanggal Diterima ?.

Point of Hire (POH)/ Tempat Diterima

lVlarital Status / Status Pernikahan bau.l,^

Gender ( L/P ) L
lD Number I No KTP $oz 943
Position / Posisi 1-a6L R 'rrL
Depaftement
Education / Pendidikan .fu,fr-
Emergency Contact

Other lnformation

t Proposed tsy, Approved By,

Contract Owner
Name Name :
BIN B/N :
 ?
SUMBAW,A,TIMUR MINING

ATTACHMENT 1
M AN POWER D AT A I N FO RM ATI O N
Photo

No. badge

Contractor Name
Full Name / Nama Lengkap DaV,u lt-.avrtDtfz*-
Address / Alamat .--fu-v-u-.--------
Local / Non Local '1.ac,.u
Home Phone / Mobile I No. HP D& I $qo l tlS &t
State / Bangsa ln?ou exv.
Place/Date of Birth ( D.O"H ) / T.T. Lahir go4Iut '3o - tl.-tfrB
(- Date of Hire / Tanggal Diterima 1A L7
Point of Hire (POH)/ Tempat Diterima

Marital Status / Status Pernikahan {5e[t-ru- [-nr,*.

Gender ( L/P ) L
lD Number / No KTP ,19-o LL
Position / Posisi ILtr.c
Departement

Education / Pendidikan ('(tna

Emergency Contact

Other lnformation

\ Proposed By, Approved By,

Contract Owner
Name Name :

B/N B/N :
 ?
SUMBAu,A?IMUP MINING

ATTACHMENT 1
M AN POWER D AT A I N FO RM ATI ON

Photo

No" badge

Contractor Name
Full Name / Nama Lengkap \+e?$^AN8-rAH
Address / Alamat ) awa
Local / Non Local I,A r a,L
Home Phone / Mobile / No. HP 00s- Lqq 4ae BBZ
State / Bangsa lNDava6r 4
PlaceiDate of Birth ( D.O.H ) / T.T. Lahir
Date of Hire I Tanggal Diterima

Point of Hire (POH) / Tempat Diterima

Marital Status I Status Pernikahan lc'aw,v

Gender ( l-lP ) L
lD Number / No KTP Sac tcj06664 'T@l
Position i Posisi WIY€K
Departement

Education / Pendidlkan ,CIVIA'

Emergency Contact

Other lnformation

By, Approved By,

Contract Owner
Name :
B/N B/N :
 ?
SUMBAWA,AIMUR MINIHG

ATTACHMENT 1
MAN POWER DATA I N FORMATION

Photo

No. badge

Contractor Name
Full Name / Nama Lengkap D

Address / Alamat
Local / Non Local

Home Phone / Mobile / No. HP

State / Bangsa lVl9drnoqtc;

Place/Date of Birth ( D.O.H ) / T.T. Lahir

L Date of Hire / Tanggal Diterima

Point of Hire (POH)/ Tempat Diterima

Marital Status / Status Pernikahan Vwm

Gender ( L/P ) L
lD Number / No KTP s?oPa( 1q0zx1a.
-+-----E4-
ql __

Position / Posisi l-{r,\?er

Departement

Education / Pendidikan .--€[l-a-

Emergency Contact

Other lnformation

.\ Proposed By, Approved By,

Contract Owner
Name : Name :
B/N : B/N :
 ?
ATTACHMENT 1
M AN POWER DAT A I N FO RM ATI ON

Photo

No. badge

Contractor Name Cr. 1\-b

Full Name / Nama Lengkap \'1 t PraTraf
Address / Alamat D,e-r*z-s
Local / Non Local LO cr^L
Home Phone / Mobile / No. HP O8t efl rsa gty
State / Bangsa : l lrtDOrY€.t.ttx
Place/Date of Birth ( D.O.H )/ T.T. Lahir DonnPu, 03 -00 -Lo o4
Date of Hire / Tanggal Diterima 71 - a.S -9OL2-
Point of Hire (POH)/ Tempat Diterima

Marital Status / Status Pernikahan l}gtutta \ar,.Wt(W

Gender ( L/P ) 1_

lD Number / No KTP
Position / Posisi l+ev? e*
Depailement
Education / Pendidikan SMA
Emergency Contact

Other lnformation

L Proposed By, Approved By,

Co ntractor Contract Owner

I
Narne Name :

BN B/N :
 ?
SUMBAWATIMUR MIN'NG

ATTACHMENT 1
MAN POWER DATA I N FORM ATION
Photo

No. badge

Contractor Name cv, b

Full Name / Nama Lengkap \L \LLA
Address / Alamat Irr+ V6an
Local / Non Local LOc-t^w
Home Phone / Mobile / No. HP

(* State / Bangsa tN 0a N,rssl ,A

Place/Date of Birth ( D.O.H ) / T.T. Lahir , __!.?__:_Q | - 2-o02_
Date of Hire / Tanggal Diterima 71 - os' lozz
Point of Hire (POH) / Tempat Diterima

lVlarital Status / Status Pernikahan M wt r\r

Gender ( L/P ) 1*
lD Number i No KTP
Position / Posisi LIC T G\K
Departement
Education / Pendidikan

Emergency Contact

Other lnformation

Proposed By, Approved By,

Contract Owner
Name Name :
B/N BIN :
 ?
SUMBAlft'A YII'IUP MINING

ATTACIIMENT 1
MANPOWER DATA INFORMAT'OS'
Fhcto

No. badge

Contractor Name e v" \\.8

Full Name / Nama Lengkap tluHDar\
Address I Alamat FAE,aBdt.t
Local / Non Local Laav
Horne Fhone / Mobile / No. HP 08r (j-7 6rtz t3L/
iA
L State I Bangsa NDO TW

PlacelDate of Birth ( D.O.H ) / T"T. Lahir , _-_rt-u__y!_ t_-g_t_:-g-J__-!a_€J

Date of Hire / Tanggal Diterima z1 - os - 1-o 7-1-
Point of Hire (POH) I Tempat Diterima

Marital Status I $tatus Pernikahan --P-*w

Gender ( L/P ) L
lD Number I No KTP SLo ga 3 ol61e1 oogb
Position / Posisi MaSav
Departement
Education / Pendidlkan

Emergency Contact

Other lnfarmation

(t-

Proposed By, Approved By,

Contnact Owner
Narne Narne :
BIN BIN :
 ?
ATTACHMENT 1
MAN POWER DATA IN FORMATION
Photo

No. badge : L,Z 11

Contractor Name a_u_ ks
Full Name / Nama Lengkap
Address / Alamat
Local / Non Local : loc-q; l
Home Phone / tt/lobile / No. HP oB t jq1 L\z Etl
State / Bangsa INPAMK A
Place/Date of Birth ( D.O.H ) / T"T. Lahir Dow?u, Zo - oi 'l*8{
L Date of Hire / Tanggal Diterima

Point of Hire (POH) I Tempat Diterima

Marital Status / Status Pernikahan : lt-aa,'1

Gender ( LiP ) L
lD Number / No KTP S2o SZ3 2 aolgs aoal
Position / Posisi Porrt ect \^4,^LiJei
Departement

Education / Pendidikan s_l--_--_-

Emergency Contact

Other lnformation

f Proposed By, Approved By,

Contract Owner
Name Name :
B/N BIN :