*Note – If requestor is not based in KK, the OHN (LCOT) or SHPP Endorser (KL) may assist to sight the

Original but a copy of

the medical Certification is to be kept by the Escort Medic ONLY.

Appendix A – HSPP Form to be completed by Applicant

Section A – Personal Particulars

……………………………………………………………….
Signature of Bearer

NAME : LA ODE MUHAMMAD ALIMUN

IC / PASSPORT NO. : C6578151
DATE OF BIRTH (DD/MM/YY) : 04 / NOVEMBER / 1984
NATIONALITY : INDONESIAN
ADDRESS : JL. PAHLAWAN, KADOLO, BAUBAU CITY
TELEPHONE OFFICE : -
NO. :- MOBILE : +62 812 4314 7547
HOME : -
BLOOD GROUP : O
KNOWN ALLERGIES : -

Section B – Next Of Kin Details

NAME : TITI IRMA AMALIA

ADDRESS : JL. PAHLAWAN, KADOLO, BAUBAU CITY
TELEPHONE OFFICE : -
NO. :- MOBILE : +62 822 9200 9643
HOME : -
RELATIONSHIP : WIFE

NSB-HSEQ-GEN-RG0120, Rev 0P. Shepherd Hibiscus Petroleum Berhad Page 1 of 2

Health and Safety Personal Passport Issuance ProcedureNSB-HSEQ-GEN-RG01PCD20 | Revision: 0 | Page 2 of 2

Section C – Employment Particulars

DATE EMPLOYED : NOVEMBER 2012
JOB TITLE : ELECTRICIAN
EMPLOYER : HD HYUNDAI HEAVY INDUSTRIES CO., LTD.
ADDRESS : 1000 BANGEOJINSUNHWAN-DORO, DONG-GU ULSAN 44032 SOUTH KOREA
TELEPHONE NO : +82 522 201560

Section D – Medical Examination Endorsement Particulars

EXAMINING DOCTOR :
NAME / ADDRESS OF CLINIC :
DATE :
VALID UNTIL :
TYPE OF MEDICAL :
REMARKS :

Section E – Safety Training Endorsement Particulars

Date Attended Valid Until Name of Training Name of Training Centre

09 JUNE 2023 09 JUNE 2028 BASIC SAFETY TRAINING STIP JAKARTA
15 DEC 2022 17 DEC 2022 BOSIET BSTC TRAINING
08 FEB 2023 CA - EBS MSTS ASIA

NSB-HSEQ-GEN-RG0120, Rev 0P. Shepherd Hibiscus Petroleum Berhad Page 2 of 2