OIL & NATURAL GAS CORPORATION LIMITED MUMBAI REGION REGIONAL SECUIRITY HQRS 1ST Floor, Vasudhara Bhavan, Bandra (E), Mumbai — 400 051. ‘Tele Fax No : -022 2699692 Non-Employee Duty Pass Application Form To be filled in duplicate, by the individual and submitted to the DGM (Secuirity) through Principal Employer. (Application should accompany Approval of ONGC’s contract executing department, proof of Date of birth, Nationality, mandatory safety training certificates, current Police clearance certificate and two latest passport size color photographs). FIRST MIDDLE SURNAME, 1.Name in full (in block letters). HARRY WALTON BELL 2.Father's Name HARRY LANCASTER BELL 3.Date of Birth (DD:MM:YYYY) 05.06.1959 A.Place of Birth : LOUISIANA, U.S.A. S.Nationality : AMERICAN nm 6.Blood Group 2 At 7.Designation : MASTER 8.Qulification CLASS I - MASTER MARINER 9.Contractor's Name 10.Contract No. and Date 11. a) C&A Verification :i) Date Issued by. b)MHA (for expatriates only) (3) Date of Application 12.Residential Address :- No. Details Present Address Permanent Address a) Flat / Room No, Swiber offshore Cons pte. Ltd 726 b) Building Name / No. 502-B wing, Delphi FAST 590 °) Street Name Hiranandani Garder Powai 4) Location / Area / Village POWAI NORTH SMITHFIELD °) Police Station POWAL UTAH 0 City MUMBAI ®) District MUMBAI hy State MAHARASHTRA USA. i) Pin Code 400 0076 84335 Dd Tel. No. kK) E-Mail ID13. Name & Tel. No. of next Kin Kelly Corona Bell / (435)535-3115 14. Visible Identification Marks Mole in the middle of neck 15. Passport Details a) Passport No, 488029928 b) Issued by UNITED STATES OF AMERICA c) Valid up to 29.10.2022 dq) 16. Type of Visa: __ Valid up to (Only Business & Employee Visas are allowed) 17. Details of Mandatory Safety Course undergone viz: a) Survival at sea Date of issue: 10.01.2010 b) Fire Fighting training _—_—Date of issue: 18.01.2010 ©) First Aid Date of issue: 02.12.2010 d) HUET Date of issue: 18, Required Work Location: __ MUMBAI HIGH NORTH - SOUTH FIELD. 19. DECLARATION: lshereby declare that the particulars given above are correct to the best of my knowledge and‘ belief. | further declare that my pass issued by ONGC security section will be surrendered torthe:security section through the principal contractor immediately on completion of its validity period/completion of contract, whichever is earlier. In case of loss of pass, | will immediately report the matter to the police and produce the FIR in original to security section Countersigned by the contractor Sarai of contract workmen (Office seal with Name & Designation) 20. DECLARATION: Attached supporting documents have been scrutinized. He has undergone the mandatory offshore safety trainings. Certified for issue of NED Passes. The photocopies of all documents are attested by company representative and they were compared with original by me. After comparison, the original certificates are returned and attested copies are enclosed herewith along with Moha Clearance copy. Date: Countersigned by Project In Charge of ONGC (With office seal) ‘OFFICE USE Pass No.: Issue Date: Valid up to: Signature of CIC Specimen Signatures: ag WA LER TEAT cag?” Wat ELA