PHOTO

SCREENING FOR HEIGHT PASS

Name of the Subcontractor:

1) Applicants Name :
2) Residential Address :

3) Age :
4) Sex :
5) Height : Weight:
6) Gate Pass No :
Name of the sub-agency with whom
7) :
engaged at present

8) Description of present job :

9) Previous experience of working at height in years

Sl No Name of Employer Duration of employment Work Experience

1
2

DECLARATION:

I hereby declare that the above information furnished by me is true & correct. I shall always wear the full body safety harness and
tie the life - line whenever working at unguarded heights of 2mtrs and above. I shall not misuse the height pass issued to me or
transfer it to any other person. I shall never come to duty or work at height / depth under the influence of alcohol / drugs

Date: Name:
Sign:

(Applicants name & Signature or LTI incase he cannot sign. In case LTI; an authorised person shall explain each point / item
to the individual and certify on behalf below the LTI

I certify that I am satisfied with the above certification of the individual for the application of height pass & request for issue of
height pass to him.

Name: Sign
Safety Officer : -
Engineer : -
Project Manager : -