SITE ID APPLICATION AND ISSUANCE FORM

(For WHITE, BLACK and VANTAGE ID) R-5: ... May 15

This form is to be completed for anyone who: 1) would like to visit Tangguh for the first time, 2) change on personnal information
3) missing ID or replace ID badges, 4) Change company/ employer.

Instruction
1. Applicant to complete section 1, Leaders to complete section 2, Issuing Authorities to complete section 3
2. CIRCLE all options applicable each question, Write in CAPITAL for any questions.
3. Aplicant to collect applied ID from the Issuing Authorities with required supporting document at TLNG site.
Note: Failure to complete accurate information may delay authorisation and the card issuance

Section 1: to be completed by Applicant

Personal data:
Name as written in Passp

Place of Birth Date of birth (dd/mm/yy) Sex Nationality Blood type Rh

M F A AB B O + -
Current Home Address

Post Code
Home Phone Mobile Phone Other Phone Email Address

Passport/ KTP No. Expired date (dd/mm/yy)

For Expatriate Only

Visa Type Visa Expired Date (dd/mm/yy) SKJ Expired Date (dd/mm/yy) IMTA Expired Date (dd/mm/yy)

Place of Hiring Jakarta Overseas, Country:

Bird Head Bintuni Fak-fak Manokwari Sorong Babo Arandai Kokas
DAV Tofoi Tanah Merah Saengga Onar Tomage Otoweri Weriagar Tomu Taroy
City:Rest of Papua
Emergency Contact Details First (primary) Secondary Thirt options
Surename
Middle name
Given / First name
Title (e.g. Mr/ Mrs)
Relationship
Is this your next of kin?
Day Phone
Night Phone
Mobile Phone
Address (only if different
with your home address)

Post Code
Applicant's Contact Person at Tangguh Site: Phone Company
Name

Applicant's Contact Person at Home Office: Phone Company

Name
Employers/ Company Address

Have you ever entered Tangguh LNG Site before? Y N

If Yes, When was your last visit (mm/yy) What was your vantage ID

What company did you work for

I confirm that I have: 1) submitted my medical data to BP Doctor, 2) attached copy of valid KTP/ SIM/ Passport
By signing this form I declare that the above information is accurate. I agree to report missing ID and return these ID card to Security
Department at the last day of my presence at Site.
Applicant:

Name : Date:

Section 2: to be filled in by Employer/ Leader/ Visit Host

Positon/ Job Title of applicant Company/ Employer

Status BP Staff BP Direct Contract TPC/ Contractor. Visitor/ Non Workforce VIP Apprentice
For Contractor/ Visitor: Validity of contract, From (dd/mm/yy) Until (dd/mm/yy)

Duration of this visit: Walk On <15 days > 15 days Date of arrival to site:
Work status at Site Rotation Visit <6 times per year Visit >6 times per year
Plan Work Location Babo Site LNG Site Villages Other:
Site Office base, (if applicable) Others: Site Phone number NA
Babo Office Admin Bldg Central Bldg Clinic Fire Station Marine Bldg Security Bldg Warehouse A
MCB/ Plant Marine vessel BP Workshop BP MT Shop Matoa Office Stinkul Office Shorebase

Does Applicant required to work inside IT&S Facilities? Y N If Yes, please contact x4554 to fill IT&S Permit form.
Does Applicant required to work inside Process Plant Area? Y N
Does Applicant required to work at NUI/ Offshore Platform? Y N
If Yes, explain why

I confirm that the applicant is needed to visit site, information provided are accurate and have met all requirements.
For contractor personnel to be approved by both parties. Approved by
Aprroved by BP Line Manager/ Site Visit Host
Contractor Manager/ Site Visit Host

Name : Date: Name: Date:

Section 3: to be completed by HSE Trainer

I confirm that the Applicant has attended appplicable induction training as per application form.
Trainer
WHITE ID induction Y N
BLACK ID induction Y N
Name: Date:

Section 4: to be completed by ID Issuance Authorities

Requirement to issue Vantage ID I confirm that data has been entered accurately and no double ID
1. Medical Certificate from BP Doctor Vantage Coordinator

Vantage ID Number Name: Date:

Requirement to issue Temporary & Permanent WHITE ID and BLACK ID

1. Copy of valid SIM/ KTP/Passport I confirm all requirement have been met and data base updated
2. Section 3 signed off Security Coordinator
3. Work Rota or Visit>6/year, duration > 15 days (for permanent)
BLACK ID Number
White ID Number Name: Date: