FORM NO: RIMS / Secu / GPMS - Con(P) / R / 008(c)

(To be filled up in capital letter)

Date: ____ / ____ /_______
To,
Gate pass section
Security Dept., Nayara Energy Ltd.

Sub: Application for New Issue / Renewal of vehicle gate pass

Sir,

Request to issue the Vehicle gate pass. The required information is given below:

Name of the Company/Firm: ______________________________________________________________

Name of Employee/Proprietor ___________________________ Contact no. ______________________

Employee/ Vendor code: __________________________ *Work order no. _____________________

Vehicle no. : ____________________ Vehicle Name _____________ Working Dept _________________

Insurance valid up to: _________________ _____ license no. ____________________________________

Type of license: __________________ Type of Entry (Own/hired/company) _________________________

I hereby certify that photo copies of following valid documents have been attached for aforesaid vehicle for which
gate pass being applied and original are being shown as per security requirements. Also it is under taken that all
documents are bonafied and no forgery has been done.

Encl: 1. Insurance 2. RC Book 3. Driving license 4.Fitness certificate (RTO) (for Heavy Vehicles Only) 5.Old Gate
Pass (For renewal only) 6. Vehicle fitness certificate provided by HSEF (Not applicable for Pool & NN Township
vehicle)

Gate allowed:
(a) Material gate (b) Refinery gate (c) Township gate (d) COT gate (e) ETEG gate
Please tick whichever applicable
Note:
1. In case vehicle used for commercial purpose then RTO formalities must be completed before applying for
the vehicle pass.
2. CNG/PNG kit fitted vehicle not allowed in refinery premises.
3. Existing Vehicle details:-
Total No of Vehicles Details of vehicles

Approved by Head of the Department

Applicant
(Not applicable for employee & Company own vehicle)
Signature Signature
Name Name
Stamp of SAP No.
contractor Date

For use of Security Department

Date of Issue: _________ Issued GP No.: ___________ Signature of issuing Authority: __________________