FORMULIR PENGAJUAN SIMPER / REQUEST SIMPER FORM

PENGAJUAN SIMPER

SIMPER Baru PIT ACCESS

New SIMPER
Perpanjangan NON PIT ACCESS
Extension

DATA DIRI PEMOHON / APPLICANT'S PERSONAL DATA

Hari/Tanggal Nama
: :
Day/Date Name
Departemen Nomor ID
: :
Department ID Number
Divisi Jabatan
: :
Division Position
Perusahaan Gol. Darah
: :
Company Blood Type

LISENSI / LICENSE
Jenis SIM
:
Type SIM
No. SIM
:
SIM Number
Masa Berlaku
:
Expiry Date

JENIS PENGOPERASIAN UNIT / TYPE OF UNIT

LV EXCAVATOR MANITOU

AMBULANCE WHEEL LOADER MIXER TRUCK

MINI BUS FUEL TRUCK LAIN - LAIN

PERSETUJUAN / APPROVAL

Pemohon HOD SQA KTT

Applicant Department Department Chief Technical of Mine

Note:
Silahkan lampirkan fotocopy berwarna SIM Polisi & KTP yang sesuai / Please attach a colour photocopy of your Police Driving
Licence & KTP.

Originator: Document No:

Frans Nico Rory HM-FRM-SHQ-082(01) – Request SIMPER
Revision Description: Issue Date: Expiry Date: Department Document Type:
First Revision June 09th, 2024 Dec 31st, 2028 SQA Form