Attachment 10.

APPLICATION FORM FOR LIGHT VEHICLE DRIVER’S LICENSE/CERTIFICATION

Due to his/her work assignment(s), the following employee is required to drive light vehicle on company roads.
Please arrange for him/her to receive: (check one)  Testing □ Training (*)

Full Name ID. No. Job Title Department/Company Vehicle Type

Sihol Pardamean Samosir FI 878161 Electrical Electrical Equipment
LV

Certification Area Requested:  (Cross Mark)

□ SURFACE MINE **) □ HIGHLAND : MP74 – MP50
□ HEAT ROAD **) /MP74 – MP66
 UNDERGROUND MINE **) □ LOWLAND : MP50 – Port-site

NOTE:
(*) Requires thorough justification for assigning inexperienced driver **) Requires
Area VP approval
Person to contact for testing or training appointment:
Name: ID. No. Job Title Department/Company Telephone
Sudirman Hutahaean 244156 Foreman Electrical Electrical Equipment 5448082

Answer the Following (Cross mark  for YES or NO):

YES NO QUESTIONS
□  1. Does this licensing request replace an existing driver?
a If YES, attach a decertification form for the driver being replaced.
b If NO, attach a justification stating why a new driver is required for this job.
□  2. Are there other drivers available who could be utilized?
If NO, Why?
□  3. Could taxi service be utilized instead of licensing this driver?
If NO, Why?
 □ 4. Is this applicant a permanent employee?
If NO, state status of employee including name of company, function, contract, etc.

And how long he/she will be at jobsite _____ years _______ months
□  5. Is this applicant a consultant, or here on a temporary basis?
If YES, answer all of the following:
a How long will applicant be at Jobsite? _____ years _______ months
b Is it possible for this employee to ride with other licensed drivers?

c What vehicle will be assigned to this applicant?

d Which other license-holders are assigned to this vehicle?

□ □ 6. If approved which vehicle (s) will this license holder routinely drive?

Date Received by S&IH Department: QMS Department:

Superintendent : __________________________________________ Date: ___________________________________________

Approved By:
Department Manager : __________________________________________ Date:

Vice President **) : __________________________________________ Date:

Of Certification Area
Concerned

Vice President S&IH : _________________________________________ Date: ___________________________________________

F-2.18.10-01-G120401d
Page 1 of 1