HCM

PERSONNEL ACCESS REQUEST L

REQUEST National
National
Personnel Type National Indirect - Service Drop Down list National
National
Purpose Access for New Personnel Drop Down list National
National
Request Access to Offshore Area Drop Down list Expatriat
Expatriat

Activity (Describe General Activity) FPU Installation

Free Text Expatriat

Student
HCML ID Card Guest
Tick on the
✘ Field Entry Permit requested
access tool
✘ HSE Passport
IT Request

PERSONNEL INFORMATION

Name (as per ID Card or Birth Certificate)* HENDRIK KURNIADI Budget Source* WP&B 2022

ID Card Number(KTP)* 3603091207860007

Position Title (as per contract)* Department* Project MDA-MBH-MDK

Date of Birth (dd-mmm-yyyy)* 12 Juli 1986 Dedicated Work Location* Offshore Area MBH & MDA Platform

Desa Lontar Kecamatan Kemiri Kabupaten

Address (KTP) Contract Number*
Tangerang

Phone/Mobile Phone Number* 0812-8104-0305 Name of Third-party Company* PT. TIMAS SUPLINDO

Desa Lontar Kecamatan Kemiri Kabupaten

Address (Current Domicile)* Emergency Contact Name* AIDY NOR
Tangerang

Service Start Date (dd-mmm-yyyy)* Emergency Contact Number* +62 812-9605-6929

Service End Date (dd-mmm-yyyy)* Relationship with Emergency Contact* Head of Crewing Dept

ATTACHMENTS

✘ ✘ ✘
MCU Result or Health Certificate Photo ID 3x4 cm (colored) ID Card/Passport

Approved AFE with breakdown position Letter of Awards

Exhibit containing position/ personnel

Approved WP&B with breakdown position
required for the contract
✘
BSS & HUET Training Certificates (and H2S Training Certificate for access to BD Field) - for HSE Passport

SUBMITTED BY:

Process Signature Completed

Requestor Name: Andreas Krisbayu Date:

Supervisor concerned 1 (if any) Name: Rudy Sardjana Date:

Supervisor concerned 2 (if any) Name: Date:

Department Manager Name: Dirzi Zaidan Date:

VERIFICATION

Process Signature Completed

HR Officer Name: Date:

HSE Officer Name: Date:

APPROVAL

Manager HSE Manager HR & GA

Rockyanto Sasabone Wisnu Prasedyoko

Date: Date:

PROCESS

Process Signature Completed

SAP Data Input - by HR Name: Date:

HCML ID Card Creation - by Security Name: Date:

ISEB Access Card Process - by Security Name: Date:

SAP Data Input (MCU) - by HSE Name: Date:

FEP/HSE Passport Creation - by HSE Name: Date:

Filing - by User Department Name: Date: