FORM VISITOR VERY HIGH PRIORITY

ID Number / Blood
No Full Position / Level Company & Full Address Emergency Contact
Name Passport *) Type
1. Prasetia Dwi Putra 6205052812900003 Surveyor PT. SCCI O 085246200462

*) Attach Letter of Assignment, Employee ID Card, Copy ID Card and/or Passport

Responsible Department : CQC Time Visit : 20 Maret 2023 To Finish To Finish

Company : PT. SCCI Purpose of Visiting : Kegiatan Stock Opname
User / PJO : Aldy Ardana Anugrah

GENERAL AFFAIR HSE

Land Transportation Request Induction Date : ………………….

for
Date To
Date To Safety Equipment :
Date To Safety Shoes, No ………………….
Airlines Reservations Itinerary Safety Helmet
Date Fr To Reflector Vest
Date Fr To Life Vest
Accommodation Form Riwayat Perjalanan
Date To Mess Num …………………. Hasil dan Kesimpulan Pemeriksaan Kesehatan
Date To Hotel
Remarks Remarks

Note : Requested by, Approved by, Approved by, Approved by

1. Put checkmark in the column selected.
2. Give an explanation on the remarks
column.
3. At latest 5 working days before
visitor arrives, GA has received
complete form.
4. Kategori : tenaga medis, dan aparat
yang bertugas pada kondisi
kedaruratan; Compliance person;
Pengapalan batubara dan un-loading
material LPB, pengangkutan LB3 dan Name : Aldy Anugrah Ardana Name : Darmansach Name : Saiful Amar Name: Arif Budiman
bahan peledak, serta pengantaran
kebutuhan logistik User / PJO Responsible Department MUTU HSE MUTU Pjs. KTT MUTU

MUTU-GA-FM-002 Rev. 04, 04-04-2020