S.H.E.

CLEARANCE FORM
REQUIREMENTS TO GET WW ID BADGE

To work at WW area, must FIT & pass SHE induction. Utk bekerja di WW harus sehat dan lulus SHE induction.
Company Name PT.Nexcom Company phone no. Working Area WW Area
Contractor supervisor Marwan Y Cont. spv phone no. Type of Work -
Contractor to fill & submit this form to WW medic 3 days prior induction, attachments copy of: health certificate (MCU), identification card & competency certificate.
Kontraktor mengisi & mengirim form ini ke WW medic 3 hari sebelum induksi, disertai copy lampiran: surat sehat (MCU), tanda pengenal, & sertifikat kompetensi.
Y N The contract will utilize operational vehicle. Kontrak ini akan memakai kendaraan operasional. (Vehicle shall inspect by WW SHE, driver must pass WW SIM).
Y N The contract will require additional local manpower. Kontrak ini akan membutuhkan tambahan pekerja lokal. (Coordinate with ER team)

Work Duration Competenc Induction

No Name Job Position y Certificate Signature* date* Induction result# MCU result#

1 Fachri Adittya Tech 1 Months Y/N 2. FIT

1.FIT
2 Marwan Yakob Tech 1 Months Y/N
3 Bintang Dwi Tech 1 Months Y/N
3.FIT

Saya sudah menerima penjelasan Aturan Kerja di WW, saya mengerti dan akan mematuhi selama bekerja di Wayang Windu area.
Jika kedapatan saya melanggar aturan kerja WW, saya bersedia ditegur & menerima konsekuensi sesuai aturan yg berlaku.
Hereby, I have received explanation of WW Work Rules; I am understood and will abide by while working in the Wayang Windu area. If caught violating the WW rules, I am
willing to be remind and receive all the consequences according applicable rules.

Contractor Spv WW/SE Contract Spv Inducted by SHE Representative Remarks:

Notes: * to fill during SHE induction; # to fill by WW SHE team; SHE induction material refer to ‘SPE.WR.101c General SHE Rules.doc’

WWMS Form: SPE.WR.101a Page 1 of 1 Print Date: 3 June 2024