Visitor Access Request Form

Doc Ref: MS-DD-3000-HSE-PRO-00xx Form No: MS-DD-3000-HSE-FRM-0087

Date: 21 july 2022 MANYAR SMELTER PROJECT Revision No: 00

Application form must be emailed to visit.request@cii-msp.com at least 24hrs prior to scheduled arrival.
Request Date : 7 Februari 2023 Date of Visit : 9 Februari 2023
Requestor Name : Hellen Eroviah Requestor Company : PT. ADHI KARYA
Pt.matrixjaya@gmail.co
Requestor Phone : 087753394000 Requestor Email : m

Purpose of Visit Area/s to Visit

Management / VIP Site Tour All Areas
Office Transaction / Meeting Office Only
Emergency Maintenance √ Specific Site Area: PIPING SITE √
Induction Training Laydown Area:
Delivery
Other (please specify):

Visitor Information
Departure Visitor ID Escort
Visitor Name Company Person to Visit Arrival Date (to be assigned Escort Name
Date upon arrival) Phone
0896766
1. Hellen Eroviah MJU Bpk.Rizqi 9/02/2023 14/02/2023 Alfat
19442

I, the requestor, declare that the visitor(s) named above, reasonably requires access, and I understand that access will only be given to the
required area. The visitor(s) will be escorted by our nominated staff with permanent access pass holder at all times while in the duration of the
visit. I will ensure that the visitor(s) and/or delivery, driver, and crew has the minimum mandatory PPE required to visit the construction areas. All
issued visitor ID cards shall be returned to the ID section at the Main Security Gate. MSP Security reserves the right to refuse any application, or
withdraw any Visitor ID pass once issued.

Applicant Printed Name and Signature

CII Approval
CII Management Approval CII Security Acknowledgement

Printed Name, Signature, and Date Printed Name, Signature, and Date
1. Subcontractor to complete this form and email to visit.request@cii-msp.com at least 24 hours before start of visit date.
2. Approved Form must be duplicated. One copy to be submitted to CII Security and another copy to be carried by the Escort during the Visit.
3. Requestor must attach a copy of the following:
a. Valid ID Card
b. Negative Antigen test (1 x 24 hours) or PCR test (3 x 24 hours)
c. Vaccination Certificate (must be fully vaccinated – 2 doses / shots)
4. The name of the visitors on this form must match their valid ID. They will be required to present their valid photo ID on arrival at the MSP site.
5. Incomplete or missing information may result in a visit denial.
6. Assigned escorts must understand their roles and must accompany visitor at all times while on site.

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 Visitor Access Request Form
Doc Ref: MS-DD-3000-HSE-PRO-00xx Form No: MS-DD-3000-HSE-FRM-0087
Date: 21 july 2022 MANYAR SMELTER PROJECT Revision No: 00