v i [NEWIEXTENTION] REQUEST FORM G.I.P AND BADGING EY] conreactor name ov. KB §| commcrnoneen —:sreorazen ) commactoexaurion = onus oraRTION B) negroes 1bemmnerao2a | Contract ourarion START DATE 30-Nov-22 mV OMTE: __34Nov23 wane REMARK (SEE NOTE) (Prot Full Mame) a @ 1 [aque nana uP ae Person | Non tocal 2 [ines Anarasula Weiser Person ual CONTRACTOR TO COMPLETE [summary of total manpower to date origina contract |Acauonl (Last request) acstional (This request) Total to date Lustiicaon Note: 1) Subcontractor Name of Subcontractor which suppty the person 2) Deeet Hire Loc: Local Dstt (Huy, Bmou, Bema) 3) Drect Hire Outsider : Non Local as tem 2 above ‘The contractor shal prove jusfcaton when request GI/Badpng for Manpower replacement and shal attach Contract Instruction of Contract Vaation for each badging/GIP request. ‘THE CONTRACTOR MUST Tr Atcchee the copy of 1D card (art Tanda Panda) Tor each parson you Proporea 2 Submit the form as attache (attachment 1 - Manponer Iformation Data) for new employee 5 tached Copy of Medal Fit Certificate issued by valid nsttuton 4, Contractor should submt REQUEST FORM cf GIP AND BACGING, a least @wortina-cays. ter to GIP being conducted Proposed by, Contgv MANPOWER DATA INFORMATION No, badge Contractor Name Full Name / Nama Lengkap Address / Alamat Local / Non Local Home Phone / Mobile / No. HP Stale /Bangsa Place/Date of Birth ( D.O.H )/T.T. Lahir Date of Hire / Tanggal Diterima Point of Hire (POH) / Tempat Diterima Marital Status / Status Pernikahan Gender (LIP ) ID Number / No KTP Position / Po: Departement Education / Pendidikan Emergency Contact (Other Information Proposed By, Contractor Name BIN ATTACHMENT 1 Approved By, ix Contract Owner Name : Teu{t] DH. BIN 2526A MANPOWER DATA INFORMATION No. badge Contractor Name Full Name / Nama Lengkap ‘Address / Alamat Local / Non Local Home Phone / Mobile / No, HP State /Bangsa Place/Date of Birth ( D.O.H)/T.T. Lahir Date of Hire / Tanggal Diterima Point of Hire (POH) / Tempat Diterima Marital Status / Status Pernikahan Gender (LP ) ID Number / No KTP Position / Posisi Departement Education / Pendidikan Emergency Contact (ther Information Proposed By, Contractor Name: BN ATTACHMENT 1 + Indika Anarasula Ji, Lintas Lakey Dusun Ncanga Desa Hu'u Local : 981369893536 Indonesia Petanang, 21 November 1998 Laki-Laki 4603172111980001 Approved By, Adal Contract Owner Name :Tou{iy D.H BIN :9c2 4