VESTIGO PETROLEUM SDN. BHD.

OFFSHORE SAFETY PASSPORT FORM

Photograph

New : Renewal : Staff : Contractor :

PERSONAL PARTICULARS NEXT-OF-KIN PARTICULARS
Full Name : Nur Anees Balqis binti Yunezzafrin Name : Wan Nurazleena Wan Mohamad Nawawi

Name to Print : Anees Balqis

Staff / IC / Passport No : 000605-03-0422 Relationship : Mother
D.O.B : 05/Jun/00 (DD/MM/YY) Sex : F / Address : No 9, Jalan Bunga Kemboja 3, Taman Muda, 56100, KL
Race : Malay Religion : Islam
Nationality : Malaysian Phone No : -
Blood Group : A+ Allergies : - Mobile No : 012-6312460
BUSINESS : Main Con / Sub Con Others MEDICAL CHECK-UP / FITNESS ASSESSMENT
Position Title : PACE Engineer AME No : MPM AME 013
Employer : EPOMS Sdn Bhd AME's Name : ROSLI RAHIM
Home Address : Date Examined : 6/Jan/24
No 9, Jalan Bunga Kemboja 3, Taman Muda, 56100, KL
Expiry Date : 5/Jan/26

Phone No : - Fax : -
OFFSHORE SAFETY & SKILL TRAINING Valid Till :
Mobile No : 014-9343056 Combined Offshore Safety Training : Y / N 23/Jan/28

APPROVAL FROM CONTRACTOR'S COMPANY Collection :

Name : (Example: Tower 1, Level 20, KLCC)

Signature & Stamp :

Date Approval :

FOR HSE DEPARTMENT USE ONLY Helicopter Underwater Escape : Y / N 23/Jan/28

Application Reviewed By : Date : H2S Training : Y N
Others : Y N
Vestigo OSP Validity till : (Expiry Date)

Approved By HSE Department :

Signature :

Name :
Signature of MOHD BUDIMAN Sponsoring Department
Applicant ZAMIR Vestigo Petroleum
Please Enclose: 1) 2 recent passport-size coloured photograph
2) Photocopy of I/C or Passport (for contractors)
3) Photocopy of OPITO Approved BOSIET training Note: Approved Copy to be given to Vestigo Logistics Section
4) Photocopy of Full Medical Report
5) Photocopy of H2S Cert (if available)
6) Photocopy of Old OSP (for renewal)

Internal