SITE ID APPLICATION AND ISSUANCE FORM

(For WHITE, BLACK and VANTAGE ID) Rev6: 1 Jan 2018

This form is to be completed for anyone who: 1) would like to visit Tangguh for the first time, 2) change on personnal information
3) missing ID or replace ID badges, 4) Change company/ employer.

Instruction
1. Applicant to complete section 1, Leaders to complete section 2, Issuing Authorities to complete section 3
2. CIRCLE all options applicable each question, Write in CAPITAL for any questions.
3. Aplicant to collect applied ID from the Issuing Authorities with required supporting document at TLNG site.
Note: Failure to complete accurate information may delay authorisation and the card issuance

Section 1: to be completed by Applicant

Personal data:
Name as written in Passport or KTP
C E R P A N D I S I DA B U T AR
Place of Birth Date of birth (dd/mm/yy) Sex Nationality Blood type Rh
S I M A L U N G U N 1 8 0 8 9 6 M F I N D ON E S I A A AB B O + -
Current Home Address
PERUMAHAN RINDANG GARDEN BLOC D2 NO 6, BATU AJI, BATAM KOTA

Post Code 29422

Home Phone Mobile Phone Other Phone Email Address
082361322611 cherpandi@gmail.com
Passport/ KTP No. Expired date (dd/mm/yy)
1 2 0 8 2 4 1 6 0 8 9 6 0 0 0 3
For Expatriate Only
Visa Type Visa Expired Date (dd/mm/yy) SKJ Expired Date (dd/mm/yy) IMTA Expired Date (dd/mm/yy)

Point of Hired Jakarta Overseas, Country: ……… INDONESIA

Papua Barat (Sorong / Manokwari / Bintuni / Fakfak) Other : …………………………………………………
IP / OP District:……………………………………. Village: …………………………………………………

Emergency Contact Details First (primary) Secondary Thirt options

Surename SIDABUTAR SIHOTANG SIDABUTAR
Middle name SURADI
Given / First name ALPON NURLIAN DINAN
Title (e.g. Mr/ Mrs) MR MRS MR
Relationship BROTHER MOTHER FATHER
Is this your next of kin?
Day Phone
Night Phone
Mobile Phone +6285264138270 085372623108 082249212687
Address (only if different
with your home address)

Post Code 53235

Applicant's Contact Person at Tangguh Site: Phone Company
Name T A N J U L 085224755751 PT. GAMMA BUANA PERSADA
Applicant's Contact Person at Home Office: Phone Company
Name L E G I S T I A N A 08118787192 PT. GAMMA BUANA PERSADA
Employers/ Company Address
JL. PERINTIS KEMERDEKAAN, PERKANTORAN PULOMAS BLOK 5 N0. 5-6, JAKARTA, 13260, RT 08/RW8, KAYU PUTIH, PULO GADUNG, EAST JAKARTA
CITY, JAKARTA 13260
Have you ever entered Tangguh LNG Site before? Y N
If Yes, When was your last visit (mm/yy) 1 0 2 1 What was your vantage ID

What company did you work for PT. GAMA BUANA PERSADA AND BSP

I confirm that I have: 1) submitted my medical data to BP Doctor, 2) attached copy of valid KTP/ SIM/ Passport
By signing this form I declare that the above information is accurate. I agree to report missing ID and return these ID card to Security Department at the
last day of my presence at Site.

Applicant:

Name : CERPANDI SIDABUTAR Date: 17-Dec-21

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Section 2: to be filled in by Employer/ Leader/ Visit Host
Positon/ Job Title of applicant Company/ Employer Skill Level Function
NDT TECNICIAN RAT LVL 1 PT. GAMA BUANA PERSADA
Status BP Staff BP Direct Contract TPC/ Contractor Visitor/ Non Workforce VIP Apprentice
For Contractor/ Visitor: Validity of contract, From (dd/mm/yy) Until (dd/mm/yy)

Duration of this visit: Walk On <15 days > 15 days Date of arrival to site:
Work status at Site Rotation Visit <6 times per year Visit >6 times per year
Plan Work Location Babo Site LNG Site Villages
Site Office base, (if applicable) Others: Site Phone number NA
Babo Office Admin Bldg Central Bldg Clinic Fire Station Marine Bldg Security Bldg Warehouse A
MCB/ Plant Marine vessel BP Workshop BP MT Shop Matoa Office Stinkul Office Shorebase
Does Applicant required to work inside Process Plant Area? Y N
Does Applicant required to work at NUI/ Offshore Platform? Y N
If Yes, explain why WORKING INSPECTION

I confirm that the applicant is needed to visit site, information provided are accurate and have met all requirements.
For contractor personnel to be approved by both parties. Approved by
Aprroved by BP Line Manager/ Site Visit Host
Contractor Manager/ Site Visit Host

Name : Date: Name: Date:

Section 3: to be completed by HSE Trainer

I confirm that the Applicant has attended appplicable induction training as per application form.
Trainer
WHITE ID induction Y N
BLACK ID induction Y N
Name: Date:

Section 4: to be completed by ID Issuance Authorities

Requirement to issue Vantage ID I confirm that data has been entered accurately and no double ID
1. Medical Certificate from BP Doctor Vantage Coordinator

Vantage ID Number Name: Date:

Requirement to issue Temporary & Permanent WHITE ID and BLACK ID
1. Copy of valid SIM/ KTP/Passport I confirm all requirement have been met and data base updated
2. Section 3 signed off Operations Security Team Leader
3. Work Rota or Visit>6/year, duration > 15 days (for permanent)
BLACK ID Number
White ID Number Name: Date:

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 Explaination of how to fill the form
(Rev1: 11 Mar 2013)
No Subject in form Explaination
Section 1
1 Name As per Passport or KTP. Seperti tertulis di Passport atau KTP.
Place of birth As per Passport or KTP. Seperti tertulis di Passport atau KTP.
Date of birth As per Passport or KTP. Seperti tertulis di Passport atau KTP.
Sex As per Passport or KTP. Seperti tertulis di Passport atau KTP.
Nationality As per Passport or KTP. Seperti tertulis di Passport atau KTP.
As per KTP or official medical data. Left blank if you do not have the data. Seperti tertulis di KTP atau
Blood type/ Rh catatan medis resmi. Biarkan kosong jika tidak punya data.
Current home address As per Passport or KTP or other formal documents
Home phone, Mobile Phone, Other Phone Other phone, i.e. satelite phone Nomor tepon rumah, HP, atau lainnya, misal telpon satelit.
Personnal email address, not your company position generic email address. Email pribadi (jika ada)
Email address bukan email posisi generic perusahaan.
Passport/ KTP No As per Passport or KTP. Seperti tertulis di Passport atau KTP.
Date of issuance As per Passport or KTP. Seperti tertulis di Passport atau KTP.
Date of expiration As per Passport or KTP. Seperti tertulis di Passport atau KTP.
For expatriate
As written in Visa. Provide visa type you are applying for. Seperti tertulis di Vis atau di form aplikasi
Visa Type visa.
Visa validity As written in Visa. Seperti tertulis di Visa.
SKJ stands for Surat Keterangan Jalan. Is a security clearence for foreigner to visit a security
sensitive locations within Indonesia. Issued by Police department. Write the issuance and expiration
SKJ expiration dates dates as written in the document. Hanya untuk expatriate.
Place where you are hired for this employement as per contract. For expatriate, write only the
country. For Indonesian National, circle only Jakarta. For local Papua hiring there are 2 categories
whether you are from Papua Barat area (circle the city) or the rest of Papua area please fill in the
Point of Hired, Bird head, DAV. blank area. More specific for IP/OP need to fill in the District and Village.

Provide detail of your next of Kin. If you do not have next of Kin, please indicate persons who close
to you but indicate NO on the subquestion asking next of kin. Next of Kin adalah keluarga langsung
yang akan dihubungi apabila pekerja mengalami kejadian darurat. Umumnya adalah Istri,Suami,
Emergency contact details anak, orang tua, saudara kandung yang diatur sesuai peraturan perundangan.
Name a person you want to meet first time when you arrive at Tangguh site. Nama orang/ atasan
Applicant's contact person at Tangguh Site yang akan ditemui oleh pemohon pada sat datang di lapangan.
Name a person you will contact at your company at home office if you got problem. Nama orang/
atasan yang harus dihubungi di kantor pusat apabila pekerja mengalami masalah darurat di
Applicant's contact person at Home office lapangan.
As per your contract. If you do not know, you should ask your self wether you have contract to work.
No one is allowed to work at site without employement contract. Nama perusahaan tertulis dalam
Employer's/ company address kontrak kerja. Setiap pekerja harus mempunyai kontrak kerja selama bekerja di lapangan.
Write Yes if you have visit Tangguh before. Pilih "Yes"apabila pernah berkunjung ke lapangan
Have you ever entered Tangguh site before? Tangguh.
Indicate month and year of your earlier visit to Tangguh. Taluis bulan dan tahun kunjungan terakhir
When was your last visit kali ke Tangguh.
Name company you work for during your last visit. Tulis nama perusahaan anda bekerja pada saat
What company did you work for kunjungan terakhir.
Section 2
This needs to be filled by employer/ Leader/ Visit host considering that many new comer do not
actually know the job title he/ she is. Leader must know and fill the job title for the applicant. Diisi oleh
atasan pekerja/ tuan rumah kunjungan mempertimbangkan bahwa tidak sedikit kejadian pekerja
Position/ Job title of applicant tidak mengetahui job title penugasan di lapangan.
Company/ Employer Name of company employing the applicant. Nama perusahaan yang mempekerjakan.
Employment and visit status of Applicant in this visit. Circle any option that is suitable. Example: a BP
VP from global visit Tangguh- should circle BP Staff and VIP. If Senior mgmt contractor circle
Contractor and Visitor. Status kepegawaian dari pemohon. Lingkari yang sesuai (bisa lebih dari
Status satu).
If Applicant is contractor, indicate date when employement contract will expire. The WHITE or
BLACK ID card will be set to valid until the date. Jika Pemohon adalah kontraktor, tulis tanggal
berakhirnya masa kontrak. Kartu WHITE atau BLACK ID akan di atur batas waktunya sesuai dengan
Validity of contract tanggal tersebut untuk pekerja rota.
For visitor, please indicate duration of Apllicant's visit. Walk on means not overnight. Untuk tamu,
Duration of this visit tulis jangka waktu kunjungan ini. Walk on artinya tidak bermalam di lapangan.
as per TASR (Transportation and Accomodation Service Request) is a separate form to be cross
Date of arrival to site refered. Sesuai TASR yang saling di acu.
Select whether Applicant is rota worker or visitor. If visitor define how frequent Applicant will visit
Tangguh practically. Pilih apakah pekerja rota atau tamu. Jika tamu perkirakan seberapa sering
Work status at site kunjungan ke lapangan akan terjadi lagi.
Select where Applicant will spent time most while at Tangguh. Pilih tempat Pemohon akan berada
Plan work location sebagian besar dari waktu selama di lapangan.
Select which building you will be based mostly. Write others if not in the available options. Pilih
Site office base gedung yang kemungkinan besar akan dijadikan base.
Yes, if Applicant will have to go into process area on shore. i.e. LNG Process train 1/ 2, utilities, ORF,
LNG Jetty, etc. Combodock and NUI offshore does not meet this criteria. If yes then you need to
Does applicant require to work inside process plant area? explain why you need to visit the area. Pilih "Yes"jika Pemohon harus masuk ke area proses.
Yes, if Applicant will have to go to offshore platform/ VRA/ VRB. If yes then you need to explain why
Applicant need to visit the area. Pilih "Yes"jika Pemohon harus mengunjungi offshore platform/
Does applicant require to work at NUI/ Offshore platform? NUI.Jelaskan kenapa.
If applicant is contractor, need signature from the contractor manager or visit host. And the BP Line
manager. Apabila Pemohon adalah kontraktor, perlu tandatangan pimpinan kontraktor dan pimpinan
Approved by Contractor manager/ site visit host BP.
If applicant is BP, only need BP Line Manager/ Site visit host signature. Apabila Pemohon adalah
BP Line Manager staff BP, cukup pimpinan BP / tuan rumah kunjungan tandatangan.
Section 3
Clear
Section 4
Clear
Section 3

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Clear

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Flow Chart - Integrated Vantage, WHITE ID and BLACK ID Application Process
Revision 3: 11 Mar 2013
Starting Point
1. Visit Tangguh for first time?
2. Change personnal data?
3. Miss/ replace ID card?
4. Move Company within
Tangguh?
No
Cancel visit
> 6 times visit Site/ year
Get Permanent WHITE ID Get Permanent BLACK ID
after attending Site after attending Site
Induction and PHOTO at Induction (if enter Plant)
Security
End Point
Aplicant BP/ Contractor Leaders OH Doctor
/Vantage Coordinator Training Coordinator Operations Security TL
(Vantage ID Card) (WHITE & BLACK ID Cards)
Missing/ inaccurate Information
via email, FAX or hardcopy
1. Fill in Application form
Yes Section 1 Fill in Application form 1. Validate Vantage databse 1. Plan Training Schedule 1. Validate WHITE and
2. prepare supporting Section 2 2. Provide Vantage ID - WHITE ID Training BLACK ID Databases
No
documents Fit to visit 3. Issue Vantage ID card - BLACK ID Training 2. Prepare ID card before
Tangguh? 4. Complete Section 4 - NUI Induction arrival
- Village Induction 3. Fill in Application Form
via email, FAX or hardcopy by Team Assistant (TA) Section 4
4. Prepare to issue ID cards
Yes
Send MCU data to BP A. Send Soft copy via email
Doctor (directly) to:
1. BP Doctor
CONFIDENTIAL DATA! 2. Vantage Coordinator 1. Issue Medical Certificate, Inform Visit Host TA of
3. Training Coordinator Inform Visit Host TA, visit Vantage ID
4. Security Coordinator may proceed
5. HR Staff 2. Update Medical Data
Note TEMPORARY or FINAL base
in the email
B. Give the original
to Applicant to bring to
Classroom
Prior Arrival at Site
At Site
1. Get Visitor ID at Security 2. Conduct the Induction
Gate entrances training as applicable per
2. Meet Visit Host request
Bring the Form in Induction 3. Sign off Section 3
Training and Ask Trainer to 4. Ensure attendance list
sign off filing and Update Training
database
Bring the Form to Security
Coordinator to get WHITE
and/ or BLACK ID card
Yes 1. Rota worker?
2. Frequent visitor to Plant> 6 times
in a year?
3. Stay duration > 15 days?
Note:
> 15 Days visit Plant Area/ year No 1. For VIP, BLACK ID card will be handled by Site Manager Team Assistant under close coordination with HSSM and Security TL
2. For VIP who arrive by Helicopter, WHITE ID card will be handled by Site Manager Team Assistant under close coordination with Security TL
Get Temporary BLACK ID 3. For WALK ON visitor, only eligible WHITE ID card at entry point
after attending Site 4. Once BLACK ID obtained, always ask permission from Ops team every time entering Plant site
Induction (if need to enter 5. Always return WHITE and BLACK ID cards to Visit Host / Security TL prior depart Tangguh Sites
Plant area) 6. ID Issuance Authorities SHALL not proceed issuance card if information required is missing, or inaccurate.
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