RISK ASSESSMENT AND ANALYSIS/‫تقييم وتحليل المخاطر‬ CONTRACTOR LOGO

SEVERITY / CONSEQUENCE (Impact/Hazard Effect) (Where an event has more than one ' Loss Type ', choose the ' Consequence' with the highest rating)
Loss Type Additional "Loss Types" may exist for an
event: Identify & rate accordingly (1) Insignificant (2) Minor (3) Moderate (4) Major (5) Catastrophic
Single Fatality or Loss of Quality of Life / Irreversible impact
(S/H) Harm to People (Safety/Health) First Aid Case/Exposure to Minor Health Risk Medical Treatment Case/Exposure to Major Health Risk Loss Time Injury / Reversible Impact on Health on Health Multiple Fatalities / Impact on health Ultimately Fatal

Material Environment harm (RST) Serious environmental harm

(EI) Environmental Impact Minimal environment harm incident with workplace Material Environment harm (RST) incident (RMT) Major environmental incident (RLT) Major environmental harm – Incident Irreversible

(BI/MD) Business Interruption / Material / Fire No disruption to operation / 1000 SR to Less than 10k SR Brief Disruption to Operation / 10k SR to Less Than 100k SR Partial Shutdown/100k SR to Less than 1M SR Partial Loss of Operation/1M SR to Less than10M SR Substantial or Total Loss of Operation / 10M SR and more
Damage & Other Consequential Losses

LIKELIHOOD Examples (Consider Near-Hits as well as actual events) RISK RATING / PROFILE
The unwanted event has occurred frequently : Occurs in order of (1) or more per year & is likely to
(5) ALMOST CERTAIN reoccur within 1 year 5 (L) 10 (M) 15 (H) 20 (Ex) 25 (Ex)
The unwanted event has occurred infrequently : Occurs in order of less than once per year & is
(4) LIKELY likely to reoccur within 5 yrs. 4 (L) 8 (M) 12 (H) 16 (Ex) 20 (Ex)

(3) POSSIBLE The unwanted event has occurred in the business at some time: or could happen within 10 years. 3 (L) 6 (L) 9 (M) 12 (H) 15 (H)

(2) UNLIKELY The unwanted event has occurred in the business at some time: or could happen within 20 years. 2 (L) 4 (L) 6 (L) 8 (M) 10 (M)
The unwanted event has never known to occur in the business or it is highly unlikely to occur
(1) RARE within 20 years. 1 (L) 2 (L) 3 (L) 4 (L) 5 (L)

Stop operation and review controls - Eliminate, Proactively manage & implement specific Actively manage & monitor – Additional Risk acceptable – Monitor & manage as
Project Name : GUIDELINES FOR RISK MATRIX avoid risk & implement high priority action plans controls/action plans-Review after 7 days controls is advised & review after 30 days appropriate with frequent review

Contract No. : RISK RATING 16 To 25 12 To 15 8 To 10 1 To 6

RA Number:‫رقم تقييم المخاطر‬ RISK LEVEL (Ex) - Extreme (H) - High (M) - Medium (L) - Low
RA TEAM (NAMES):‫اسماء فريق التقييم‬ DESIGNATION SIGNATURES WORKPLACE / TASK / ACTIVITY / PROCESS NAME: ‫المعدة‬/‫العملية‬/ ‫المهمة‬/ ‫الموقع‬ DEPARMENT / AREA:‫المنطقة‬/‫ االدارة‬:

1. DATE:‫ اتاريخ‬:
2. NEXT REVIEW DATE / ‫ تاريخ مراجعة القادم‬:
SCAFFOLDING ERECTION, DISMANTLING, MODIFICATION
3. APPROVED BY MANAGER / SUPERVISOR:‫اعتمد من قبل‬
4. SIGNATURE:‫التوقيع‬
RISK
HAZARD IDENTIFICATION/‫تحديد المخاطر‬ CONTROL/‫وسائل التحكم‬ ASSESSMENT RISK REDUCTION ACTION PLAN/ ‫خطة العمل لتقييم المخاطر‬
‫تقييم المخاطر‬

Consequence

Consequence
Risk Issue

Risk Ranking
Likelihood

Likelihood
‫الرقم المتسلسل‬

(Possible Incident) (What can go wrong) (Improve Existing Controls/ Implement Follow up By Whom (Name) & By

Ranking
Workplace/ Activity/ Process/ Controls
Hazards Existing Controls
Item #

Implemented (Yes
Equipment/ materials
‫االخطار‬ (Accident/ Ill health to person, fire or ‫وسائل التحكم المتوفرة‬ new controls) When (Date) / No)/‫هل تم التنفيذ‬
‫ المواد‬/ ‫المعدات‬/‫موقع العمل ظمهمة العمل‬ property loss) ‫التحكم والسيطرة االضافية‬ ‫التاريخ‬/‫المهمة المعنية بالتنفيذ‬ ‫ال‬/ ‫نعم‬
/‫ المخاطر المحتملة‬/
• Permit to Work shall be obtained as a pre- • Permit Receiver shall be trained and
requisite to perform work authorized by the Manager to receive a
• Work shall not be started until duly approved Permit to Work
• Accident resulting serious injury or death to Permit to Work is available at site and that Safety ●Permit Receiver shall be responsible to
Toolbox meeting was conducted 0 oversee for the safety of all workers under 0
worker
his Permit to Work
• Work shall not proceed without the presence of
approved Permit to Work with the Permit Receiver
overseeing the activity
• Unathorized work to be performed within ● A safe work practice shall be implemented to • All workers attending the toolbox meeting
a defined location and boundary reduce the possibilities of accident / incident shall sign on the attendance sheet attached
●Permit Receiver and to the specific Permit to Work
Permit Issuer shall visit together at the site to
• Significant property and appurtenances ensure that workplace hazards are adequately
damage identified and mitigating measure shall be
established

1 Obtain Permit to Work
• Uncontrolled personnel entering a
restricted location
● Permit to Work shall be displayed at the ● All workers shall attend the toolbox
worksite meeting on a daily basis conducted by the
● Permit Receiver shall not leave the area for the Supervising Engineer, Foreman and Permit
• Loss of production whole duration of work 0 Receiver 0
●Permit Receiver shall account all workers under
his Permit to Work before the start of work
• Significant cost due to damages

● Manager, Supervisor, Foreman and all workers ●

shall adhere to all requirements set forth in the ●
Permit to Work, Risk Assessment, Method
• Unidentified hazards with unplanned Statement, Job Safety Procedure and other
• Governmental violation relevant safety practices and standards 0 0
safety mitigating measures

1 of Rev. 2 (08 - April - 2019) Project Business Unit


• Inadequate coordination and area control
• Environmental complaint
protocol
• Lack of safety awareness and knowledge
for the job
• Miscommunication between work teams
Site preparation, mobilization of • Incorrect manual handling/ lifting of
2
materials, tools and equipments. material
• Poor Access/Egress
• High ambient temperature
• Congestion due to other ground activity
• Struck by maneuvering heavy equipment
• Trailer blind spot
• Inexperienced or untrained operator
Positioning of crane and trailer in
3 preparation for loading or
unloading • Site access limitation
• Soft ground /Uncompact fill
• Overhead/Nearby obstructions
• Struck into adjacent structures or worker
2 of
● Site Manager, Supervising Engineer, Foreman
shall designate a Permit Receiver competent
enough to take responsibility in securing the
Permit to Work
• Obtain valid permit to work.
• Ensure that all workers are given a HSE induction
prior to deployment on site.
• Conduct safety toolbox meeting and discussed
the work procedures prior to start of work.
• Physical Injury from poor safety awareness • Ensure that all workers are provided with all the
required Personal protective equipment for
minimum and general requirements.
• Proper coordination and communication shall be
observed between work teams.
• Activities that has the potential to impact each
• Physical injury from simultaneous activity other must be avoided and stop.
• Ensure correct body positioning and manual
lifting procedures.
• Only 20 kg allowed lifting by an individual. Use
• Muscular injuries (back pain, strain, fractures) buddy system if load exceed.
• • Use hand protection (cotton gloves minimum)
Pinch/crash points resulting hand injuries during handling of materials.
• Keep hands away from pinch/crash points
• Access pathways to be kept clear from any
obstruction.
• Conduct housekeeping before, during and after
work to ensure free Access/egress.
• Physical injury from slip, trips & fall
• Provide sufficient ventilation (i.e. AC, blower, fan
etc.)
• Provide sufficient drinking water and scheduled
breaks.
• Heat Stress (stroke, cramps, skin rashes etc.) • Drinking containers shall be protected from
direct exposure from the sunlight.
• Provision of rest shelter area if outside the
building.
• Work Supervisor obtaining Work Permit and SWP
• Serious accident that may lead to severe before the start of material delivery and crane
injury or death positioning.
• Coordination of Site Engineer to the
manufacturer of the delivery date and number of
panels to be delivered to help avoid over-
• Vehicular accident due o collision congestion of access and public roads.
• Damage to trailer or other adjacent heavy • Trained Flagman/spotter guiding the
equipment crane/trailer when going into work location
• Verification of Crane Operator’s 3rd party
certification and Trailer Drivers driving license
• Serious accident that may lead to severe before allowing them to enter the site.
injury or death
• Vehicular accident due to collision • Barricading the exclusion zone/ working radius
once crane and trailer are in position
• Responsible Engineer and his Supervisor/
• Significant property damage Foreman inspection of exclusion zone/staging area
for compaction and level of the ground.
• Provide flagman and spotter to guide the trailer
• Significant property damage operator when maneuvering for its position
• Barricade the working area around the trailer
and crane to prevent unnecessary workers to
• Serious accident that may lead to severe enter the area
• Safety signage shall be posted to communicate
injury or death
the hazards and activity
Rev. 2 (08 - April - 2019)
●
●
0 0
• Close supervision required, supervisor and
foreman must be present at site.
• Take precautionary actions to make safe
work environment.
0 0
• Close supervision required, supervisor and
foreman must be present at site.
• Take precautionary actions to make safe
0 work environment. 0
• Provide material handling equipment for
transport of heavy and large materials /
equipment.
• Provide Manual handling Training to the
0 workers. 0
• Any obstructions shall be moved and kept
materials away from any access. Keep work
area free from loose tools and materials.
• Provision of proper work access (i.e.
0 ladder). 0
• Conduct temperature/humidity monitoring
to ensure safe working condition.
• All personnel must undergo in a Heat Stress
Awareness Training.
• Post some heat stress campaign at the site
0 to increase the workers awareness. 0
• Coordination with other discipline through
general TBT one day before the mobilization
0 0
of Crane and Trailer.
• Supervisor/Foreman with the Crane/Trailer
operator making walkthrough of the access
and work area before entering site.
0 0
●
0 ● 0
●
●
0 0
●
0 ● 0
●
●
0 0
●
●
0 0
●
●
0 0
Project Business Unit

• Uncertified Lifting Equipment &
Accessories
• Area uncontrolled
• Unauthorized Lifting Activity
• Incompetent Operators, Riggers and banks • Unintentional release of load
man
• Unstable set-up of crane or lifting
equipment
• Exposure to strong wind above 32 kph,
sand storm, heavy rain
Scaffold Material unloading using
4 lifting equipment such as boom
truck or crane
• Improper rigging practices and technique
• Improper speed of boom swing
3 of
• Damage to equipment and load
• Equipment Failure
• Damage to nearby equipment and facilities. • • Ensure that the activity has a valid work permit.
Crush injuries to personnel
• Trap injuries – fingers being caught between
sling/chain and load
• Damage to equipment and load
• Fall and topple of crane
• Accident resulting injury or death to
personnel
• Significant property damage to crane and
offices building
• Uncontrollable load swing
• Jerking of load resulting to sudden increase suspend the lifting activity
in load weight
• Vision impairment
• Collapse or overturning of lifting equipment
• Miscommunication
• Accident resulting injury to personnel
• Uncontrolled load swing
• Sudden increase in load weight
• Load collapse or fall
• Lifting equipment checklist shall be used prior to
the start of activity to ensure lifting equipment is
in good condition
• Ensure that the Safe Working load is clearly
indicated on the equipment.
• Equipment, operator and rigger must be third
party certified
●
• Check first for soil stability on the crane pad
• Ground or crane pad shall be compacted and
stable enough to carry the weight of the crane
• Out rigger must be fully extended on a stable
and flat even ground
• Outrigger spreader mat pad shall be 4 times the
diameter of outrigger pad
• All tires of the crane must be elevated at least 3
inches from the ground for the whole body to act
as the counter weights
• Crane side lifting shall be discourage
• Make sure to locate center of gravity of the load
before final lift
• Pre-lift shall be done to elevate the load for at
least 6 inches from the ground in order to find and
adjust the balance of the load
• Load shall be lowered, placed on the ground and
• Crane’s boom shall be retracted and facing
opposite the wind direction
• Monitor wind speed and stop lifting job if wind
speed increases more than 32 km/h
• Outrigger shall be deployed while crane is in
standby position
• Engage trained flagman and third party certified
rigger to do lifting activity safely
• Operator and rigger shall communicate and
agree on the signal that will be using
• Rigger shall be competent enough to rig the load
properly and efficiently
• Standard rigging practices shall be followed
• There shall be minimum of two (2) taglines
attached to the load on opposite direction to guide
the load
• Crane operator shall control the speed of the
boom to prevent the load from over swaying
• Rigger or signal man shall provide guidance to
the operator when the load swing rapidly
• There shall be minimum of two (2) taglines
attached to the load on opposite direction to guide
the load on its destination and drop off point.
Rev. 2 (08 - April - 2019)
• Lifting equipment to be used shall comply
as per the load chart and lifting plan
requirements.
0 0
• Before unloading of scaffold material
equipment must be inspected by supervisor.
0 0
• Inspection to be done for all lifting
accessories& tackles
0 0
• Preplan the area where crane will be
positioned, ground must be leveled and
compacted
• Crane operator shall evaluate the ground if
capable to withstand the position of the
crane
0 0
• Safety Officer shall monitor the wind speed
while lifting activity is ongoing
0 0
●
0 ● 0
●
0 ● 0
• Maintain proper communication in
between rigger and operator
0 0
• Supervisor and Foreman shall motivate the
operator to swing the boom smoothly and
0 not hastily 0
●
●
0 0
●
●
0 0
Project Business Unit

• Struck by or collision with other equipment
or structure during lifting and swing of boom
• Unauthorized Erection/ Dismantling/
Modification
• Working on Substandard/Incomplete Scaffold scaffold erection is incompliance with standard.
• Incompetent Scaffold Erectors/ Dismantlers
may result into collapse of scaffold structure.
Scaffold Material & Workplace
5 • Unstable base or lose ground condition may boards) as required prior to the erection of the
inspection
• Unstable & Loose Ground
• Use of Substandard or Damaged
Scaffolding material
• Erection near openings
• Erection/ Dismantling near or adjacent to
public or nearby worker
4 of
• Barricade lifting radios and provide proper notice • Establish safe distance between heavy
and sign boards equipment
• Each heavy equipment shall be designated with a
signal man or spotter to guide the operator of the
its blind spot or out of the line of sight
• Vehicular accident • Crane safety feature to detect proximity of other
equipment shall be tested, checked and in good
condition 0 0
• Crane’s safety feature to stall once unsafe • Designate dedicated person to control
situation occur must be in good operating heavy equipment movement and prioritizing
condition and shall not be bypassed unnecessarily its operation • Site
• Establish equipment access and shall be free management plan shall be prepared,
from any obstruction • approved and implemented to avoid
Designate parking area property damage and personnel accident
•Collision with other structure resulting Injury • Designate location for unloading of materials
to personnel or Property damage of adjacent • Designate spotter and flagman to guide all 0 0
structure or appurtenances equipment and personnel movement
• All Erection/Dismantling of Scaffolds shall have • Inspection & monitoring of activity by
Permit to Work prior to the activity. safety personnel, Site engineer, Supervisor &
• Announcement of Work Shall be done to the Site Manager.
affected areas.
• Permit Issuer & Receiver should be trained.
• Scaffold should be erected in compliance with
• Unauthorized erection, dismantling and standard and owner rules, regulations.
• Make sure yellow tag is installed at access while
modification of scaffolds may affect on-going 0 0
erection is going on.
activities and endanger nearby workers.
• Don’t allow any other activity while erection is
going on.
• Only Certified Scaffold erectors should • Task specific training and tool box talk to
Erect/Dismantle/Modify any scaffolding structure. be given related to this specific activity.
• Scaffold inspector will inspect that ongoing
0 0
• Ground shall be checked prior to erection and • Inspection of workplace is required
may use engineering controls (compaction, sole • Effective Supervision is required
• Obtain Work permit
result into collapse of scaffold resulting in scaffolding. 0 • Experienced manpower for specific task is 0
personnel injuries. needed
• Only approved materials shall be used as per • Supervision should be done by site scaffold
OSHA requirements. supervisor.
• Visual Inspection shall be done by the scaffolding • Inspections should be done by Safety
• Collapse of scaffold Structure. inspector prior to allow use of scaffold platform. 0 personnel. 0
• Make sure that the scaffold is installed on firm • Prior Inspections should be done by Safety
ground and at safe distance from nearby openings personnel.
• Falling in open holes resulting in major injury or excavations.
• Hard barricades & proper covers need to be 0 0
even fatality.
provided on openings.
• Make sure area is barricaded to avoid entry of • Safety Nets to be provided (If necessary)
unauthorized workers, sign is posted that erection
• Affected area of Erection/Dismantling may of scaffold is going on.
• Supervisor shall oversee the activity to ensure
endanger the safety of public and nearby 0 0
the safety of nearby public.
workers
Rev. 2 (08 - April - 2019) Project Business Unit

• Handling of scaffold standards & ledgers
• Improper manual handling or poor body
posture
• Loose tools & materials
• Standing on incomplete scaffolding
structure
Assembling, modification and
6
dismantling of scaffold structure
• Use of unsafe scaffold structure
• Weak or damaged platform without edge
protection
5 of
• Only certified scaffold erectors should erect or • Effective monitoring by safety personnel&
dismantle scaffoldings. ensure the material handling procedures are
• Ensure Material Handling Training is conducted followed
for workers
• Skilled Labor
• Proper Supervision
• Secure hand tools with lanyard.
• Use bull bag when hoisting up and/or lowering
down materials
• Pipe shall be tied securely when hoisted up
• Fall of materials may cause property damage during erection or lowering during dismantling
• There shall be no personnel standing below 0 0
or injury to workers
when lowering scaffold pipes
• Barricade shall be installed around the scaffold
structure only allowing scaffold erectors inside the
workplace
• Implement proper manual handling techniques. • Safe Work Procedure should be discussed
• Use of mechanical means for handling and & shared,
transportation of heavy materials. • Ergonomic Survey of Activity to be
• Back injuries, muscle pain and cramps. 0 0
conducted.
• All tools shall be tied off to workers belts to • Warning Signage to be displayed
prevent falling of tools. • Barricades to be provided to restrict
• Working platforms shall have toe boards to avoid unauthorized entry in scaffold area.
falling of materials from edges. • Parallel working shall not be allowed at any
• Loose material should not be stored on platform. time
• All materials shall be placed on a bull bag or
other means to contain to prevent from falling
below
• Falling of tools and other materials can hit • Ensure Material Handling Training is conducted
for workers 0 0
nearby workers.
• Skilled Labor
• Proper Supervision
• Secure tools with lanyards.
• All workers working above 1.8m shall be • Life line should be used secondary
provided with Safety Harness with double lanyard protection.
as minimum PPE.
• 100% tie off policy to be followed.
• Proper hand rails & mid rails should be fixed
• Workers shall follow 3 point contact rule when
ascending and descending of the ladder
• Workers shall not hold or carry any materials or
tools when climbing the ladder
• Worker fall from height resulting to major • Ladder shall be installed at all level of the
injury even Fatality could occur. scaffold while erection is still going on 0 0
• Climbing on the scaffold without ladder shall not
be allowed
• Scaffold workers shall communicate properly • It should be Controlled by the site
when dismantling to ensure not putting anyone at supervisor
risk of falling • Proper hand rails &
mid rails should be fixed
• Could lead to collapse of structure & resulting • Workers shall follow 3 point contact rule when
0 0
major injuries to worker ascending and descending of the ladder
• Standard OSHA planks should be used as • Proper Inspection of material to be done
platform • Medical Fitness of Height Worker
• Proper supervision is required by competent
person during erection of edge protection like toe
• Collapse of scaffolding structure resulting to guard, hand rail, mid rail.
Fall of person or Fall of material • Use of Full body Harness 0 0
• Retractable life lines (If necessary)
Rev. 2 (08 - April - 2019) Project Business Unit

• Fall from height, contact to sharp edges or
• Damage or faulty ladders
broken steps causing cuts and bruises
• All ladders to be inspected for damage prior to
use.
• Regular scheduled inspections shall be done
using ladder checklist.
• Make sure that safe access is provided to
scaffold erector
• Ladder shall be erected with 75 degrees angle or
1:4 base to height ratio
• Ladders shall be tied and secured to prevent
from slipping and fall
• Color coding of equipment’s to ensure
inspection status,
• Random inspection& checks of
equipment’s,
• Damage or defective ladder shall be
marked red or do not use and shall be
brought out of the project site
0 0

• All activities shall be stopped at high winds, • Environmental Monitoring

• Exposure to outdoor weather
• Extreme humid environment
• Extreme Temperature
EXTREME TEMPERATURES & sandstorm. • Cold water dispenser availability
• Cool drinking water must be present and
accessible to all the workers.
• Heat stress • Immediately after rainfall scaffold erection
• Unconsciousness, /dismantling shall not proceed due to slippery
• Dizziness condition of tools and materials
• Nausea • Adjust work timing and exposure of the workers
• Rashes • Allow frequent rest time if needed
• Collapse of scaffold structure resulting in • Provide rest shelter with shade near to the
major injuries even fatality workplace 0 0
• Poor illumination • Provide supplemental hydration powder or
• Heavy wind liquids.
• Sand Storm • Reminds to drink plenty of water
• Poor visibility
• Extreme Humidity will lead to excessive
sweating, fatigue, breathing stress

• Manual handling can lead to musculoskeletal

• Manual handling disorder • Facilitate training for manual handling.
• Observe proper posture during manual lifting, 0 0
pushing, pulling, etc.

• Provide storage box for lifting gears
• All lifting web sling belt and wire rope must be
coiled after each day of work.
• Materials lying on the ground. • Property damage • Labeling of storage box (good items, scrap /
damage items, by capacity, etc.)
Housekeeping, clearing the area
with all used materials, tools and
7 equipment and brought to the • Accident resulting injury to worker / Slip, trip, • Remove all unwanted / protruding materials /
designated storage and disposal • Protruding object / materials at the site falls object at the site
area
• Provision of standby fire extinguisher
• Periodical inspection and / or color coding for
fire extinguisher
• Provision of waste skip in the strategic location
• Uncollected / scattered rubbish • Fire at the site with marking
• Provision of color coded waste bins at the site
• Daily inventory of the equipment •
Training / awareness regarding the
segregation of waste
0 • Immediate disposal or sending the damage 0
one to the store keeper
• Good housekeeping at the site
0 • Daily toolbox meeting 0
• Records and registry for fire extinguisher
• Records /
registry for the quantity of waste disposed
0 0

• Permit Receiver shall ensure that housekeeping

• Significant property and appurtenances in done before, during and after the work
damage • Electrical equipment shall be properly secured,
• Unsecured electrical equipment, energized distribution board closed and padlocked
equipment 0 0

• Undisposed waste materials
• Poor housekeeping
• Unaccounted workers
8 Closing of Permit to Work
• All waste materials generated from the work • Supervising Engineer and Foreman shall
shall be disposed properly and shall not be left adhere to the proper housekeeping and
• Governmental violation unattended at the worksite 0 storage of materials at the designated 0
location
• Permit Receiver shall account all worker under ●
his Permit to Work and ensure all have signed out ●
• Accident resulting serious injury or death to on the attendance sheet and clear of the area
0 0
worker

• Site Manager shall be responsible on the ●

effective implementation of the Permit to Work ●
• Inadequate communication • Loss of production 0 0

• All materials used at the site such as chemicals, ●

flammable and combustible materials shall be ●
• Poor storage of chemical, flammable and stored at the designated storage at the end of
• Environmental complaint 0 0
combustible materials and etc. each day

• Permit Issuer shall visit the work location to • Mobile equipment shall properly parked on
verify good housekeeping was conducted before a designated equipment laydown
• Unattended unsafe condition • Significant cost due to damages closing the Permit to Work 0 0

● 0 ● 0
●
● ●
●
0 0
● ●
6 of Rev. 2 (08 - April - 2019) Project Business Unit
 ● 0 ● 0
● ●

7 of Rev. 2 (08 - April - 2019) Project Business Unit

RA Prepared by : RA Accepted by : RA Approved by SEC / Safety Rep: RA Aprroved by SEC-HV&EHVPD:
Name & Sign Name & Sign Name & Sign Name & Sign
Desgination Desgination Desgination Desgination
Date Date Date Date