Hindustan Urvarak & Rasayan Limited

(Joint Venture of IOCL, NTPC, CIL, HFCL, & FCIL)

Barauni Urvarak Nagar, Begusarai Bihar-851115

Name of contractor:- Certificate Serial No:-

PHOTO
Employee/Labour Details-
Name:- Identification Mark:-
Father’s Name:- Residence Address:-
Age:- │Sex:-

Name of Employee/Labour:
Sl no Job Detail Specific Tests Report Remark
1 Welder/Painter/Abrasive Blaster Chest X-Ray
2 Driver /Crane Operator (a) Chest x-ray (b)Spirometry
(c) Colour Blindness
(d)Audiometry
3 Scaffolder /Driver Vertigo /Acrophobia(working above 10
meters)
4 Food Handlers/Rigger Urine & Stool Analysis
5 Tower Crane Operator Spirometry
6 Medical staff/Nurse HFT/Heart Scan e.g.MRI,Stress test
etc
7 Fitter/Electrician/Technician,work at height

Job Specific Test:

1 Height 6 Weight(kg)
2 Heart Rate 7 Blood Pressure
3 Ear /Nose/Throat 8 Vision
4 Physical Disability 9 Dental
5 Blood Group 10 Haematology

Certificate Doctor Detail & Declaration:

I hereby certify that I have personally examined (Name)………………………………………………………

Residing at ……………………,………………………who is desirous of being employed in building and
construction work & that his/her age as nearly as can be ascertained from my examination is
…………..
Year & that he/she is fit for employment in……………..as an adult/adolescent & in my opinion he is
physically & mentally fit to perform work.
Name of Doctor
Qualification
Registration No-
Address
 Stamp & Signature of Doctor

Hindustan Urvarak & Rasayan Limited

(Joint Venture of IOCL, NTPC, CIL, HFCL, & FCIL)
Barauni Urvarak Nagar, Begusarai Bihar-851115

APPLICATION FORM FOR PERMANENT GATEPASS

1. Contractor Name:
Type of Pass: Executive Staff Contract labour

First Name Middle Name Last Name

2. Full Name:

3. Father’s Name:
PHOTO
4. Date of Birth: Blood Group:

5. Corresponding Address: Permanent Address:

Matriculation Intermediate Graduate Master U/E

6. Qualification:

7. Aadhaar Card No: ID Mark:

8. Area of Work: North Side South Side Township Other

9. Shift: Day Night Round the Clock

10. Labour /Staff/Supervisor: Unskilled Semi Skilled Skilled High Skilled

11. Mobile Number: Emergency Contact Number:

12. Designation: Fitter Electrician Rigger Technician

Helper Staff Others

Declaration

All the information stated above are true and correct to the best of my knowledge in case it is
found wrong action as deem fit can be taken against me.
 Recommended By Consultant/Agency/Contractor Signature of Applicant
(Name, Designation) SEAL

Hindustan Urvarak & Rasayan Limited

(Joint Venture of IOCL, NTPC, CIL, HFCL, & FCIL)
Barauni Urvarak Nagar, Begusarai Bihar-851115

Pass Application Date Gate Pass No

APPLICATION FORM FOR VEHICLE PERMANENT GATEPASS