NEW/EXTENTION

REQUEST FORM G.I.P AND BADGING

CONTRACTOR TO COMPLETE

CONTRACTOR NAME : CV. IKB

CONTRACT NUMBER : STM-CN22-017-C
CONTRACT DESCRIPTION : DRILL SITE PROPARATION
REQUEST DATE : 22-11-2022
CONTRACT DURATION START DATE : 26-Oct-22
EXPIRY DATE : 25-Oct-23

REMARK (SEE NOTE)

NAME
NO. BADGE POSITION
(Print Full Name) Previous
(1) (2) (3)
Bagde
1 Awaludin Helper Person Local

2 Salahudin Helper Person Local

CONTRACTOR TO COMPLETE

Summary of total manpower to date

Original contract :
Additional (Last request) : 62
Additional (This request) : 2
Total to date : 64
Justification :

Note :
Please mark :
1)
Subcontractor : Name of Subcontractor which supply the person
2) District (Hu'u, Dompu, Bima)
Direct Hire Local : Local
Direct Hire Outsider3): Non Local as item 2 above
The contractor shall provide justification when request GIP/Badging for Manpower replacement and shall attach
Contract Instruction or Contract Variation for each badging/GIP request.

THE CONTRACTOR MUST :

1. Attached the copy of ID card (Kartu Tanda Penduduk) for each person you proposed
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
4. Contractor should submit REQUEST FORM of GIP AND BADGING, at least 6-working-days
prior to GIP being conducted

Proposed by, Approved by: Approved by: Approved by:

Contractor HR Dept Contract Owner Safety Dept

 ATTACHMENT 1
MANPOWER DATA INFORMATION

No. badge :
Contractor Name : CV. IKB
Full Name / Nama Lengkap : Awaludin

Jl. Lintas Lakey, Desa Daha Kec. Hu'u, Kab. Dompu

Address / Alamat :
Local / Non Local : Local
Home Phone / Mobile / No. HP : 083854010222
State / Bangsa : Indonesia
Place/Date of Birth ( D.O.H ) / T.T. Lahir : Daha, 03-04-1996
Date of Hire / Tanggal Diterima :
Point of Hire (POH) / Tempat Diterima :
Marital Status / Status Pernikahan : Single
Gender ( L/P ) : L
ID Number / No KTP : 5205030304960002
Position / Posisi : Helper
Departement : Konstruksi
Education / Pendidikan : SMA
Emergency Contact :

Other Information :

Proposed By, Approved By,

Contractor Contract Owner

Name : Name :
B/N : B/N :
 ATTACHMENT 1
MANPOWER DATA INFORMATION

No. badge :
Contractor Name : CV. IKB
Full Name / Nama Lengkap : Salahudin

Jl. Lintas Lakey, Desa Marada Kec. Hu'u, Kab. Dompu

Address / Alamat :
Local / Non Local : Local
Home Phone / Mobile / No. HP : 085337661280
State / Bangsa : Indonesia
Place/Date of Birth ( D.O.H ) / T.T. Lahir : Hu'u, 05-06-1998
Date of Hire / Tanggal Diterima :
Point of Hire (POH) / Tempat Diterima :
Marital Status / Status Pernikahan : Kawin
Gender ( L/P ) : L
ID Number / No KTP : 5205030505980002
Position / Posisi : Helper
Departement : Konstruksi
Education / Pendidikan : SMA
Emergency Contact :

Other Information :

Proposed By, Approved By,

Contractor Contract Owner

Name : Name :
B/N : B/N :