Document No: MER-SEC-IMS.

07-F04
MERIAN OPERATIONS Version No: 2.1

FORM Issue Date: June 2018

Page No: 1 of 1

Laptop & Devices Registration Form

1. Laptop & Device Owner Registration
First Name:
Last Name:
Company:
Department:
Badge / GID #:

2. NEWMONT SURINAME Laptop Registration

NEWMONT SURINAME Provided Laptop
Brand Service Tag Model

NEWMONT SURINAME Provided Mobile Phone

Brand Serial / IMEI Phone Number

3. Personal Device Registration

Personal Devices / Phones
Brand / Device Serial / IMEI Model / Phone Number

4. Permit requested for : (please tick applicable boxes )

 Merian Site  Process Plant (only if approved by Process Manager)

Newmont Issued Laptop Newmont Issued Laptop

Newmont Issued Mobile Phone Newmont Issued Mobile Phone

Personal Devices /Phones Personal Devices / Phones

Declaration: I hereby declare that the information provided by me is correct and understand that it is my
responsibility to notify Newmont Suriname Security of any change(s).

Signature: ……………………………………

Issued Date: ……/……../……. Expiration Date: ……/……../…….

Please present this form to the Security Department to obtain a respective badge issued, which will be assigned to the
owner for verification purposes every time when entering or leaving the Newmont Suriname Facilities.

Author: Don Loupret To Be Reviewed: May 2021

Approved by: Dries Hugo Print Date:

The latest version of this document is available on the Newmont Suriname Network as a “read only” file
THIS DOCUMENT IS UNCONTROLLED IN HARDCOPY FORMAT