Annexure: B

OIL & NATURAL GAS CORPORATION LIMITED

MUMBAI REGION
REGIONAL SECURITY HQRS
st
1 Floor, Vasudhara Bhavan, Bandra (E), Mumbai 400 051
Tele Fax No. 022 2269 9692

Non-Employee Duty Pass Application Form

To be filled in duplicate, by the individual and submitted to the DGM (Security) through
Principal Employer. (Application should accompany Approval of ONGCs 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 SURNAME MIDDLE

1 Name : PLEASE FILL UP PLEASE FILL UP PLEASE FILL UP
(in Block Letters)
2 Fathers Name : PLEASE FILL UP

3 Date of Birth : PLEASE FILL UP

(DD:MM:YYYY)

4 Place of Birth : PLEASE FILL UP

5 Nationality : PLEASE FILL UP

6 Blood Group : PLEASE FILL UP

7 Designation : PLEASE FILL UP

8 Qualification : PLEASE FILL UP

9 Contractors Name : M/s L&T Hydrocarbon

Engineering Ltd.
10 Contract No. and Date : MR/ES/MM/T&I-DDP/03/2017/P86SC17001,Dated:
21.11.2017 AND
MR/ES/MM/BWPRP-4/10/2017 (P851C17006) dated
10.11.2017
11 a) C&A Verification : (i) Date: NA (ii) Issued by: NA

b) MHA (for expatriates : Date of application:

only)
12 Residential Address : PLEASE FILL UP
N Details Present Address Permanent Address
o
a. Flat / Room No. PLEASE FILL UP
b. Building Name/No. PLEASE FILL UP
c. Street Name PLEASE FILL UP
d. Location/Area/Village PLEASE FILL UP
e. Police Station PLEASE FILL UP
f. City PLEASE FILL UP
g. District PLEASE FILL UP
h. State PLEASE FILL UP
i. Pin Code PLEASE FILL UP
j. Tel No : PLEASE FILL UP
k. E-mail ID PLEASE FILL UP
13 Name & Tel. No. of next of PLEASE FILL UP
Kin

14 Visible Identification Marks : PLEASE FILL UP

15 Passport Details : PLEASE FILL UP
a. Passport No. : PLEASE FILL UP
b. Issued by : PLEASE FILL UP
c. Valid up to : PLEASE FILL UP

16 Type of Visa (Only Business : N/A Valid Up to : N/A

& Employee Visas are
allowed)

17 Details of Mandatory Safety Course undergone viz :

a) Survival at Sea : Date of PLEASE FILL UP
Issue :
b) Fire Fighting training : Date of PLEASE FILL UP
Issue :
c) First Aid : Date of PLEASE FILL UP
Issue :
d) HUET : Date of PLEASE FILL UP
Issue :
18 Required Work Location : ONGC Offshore field- Transporation & Installation - Daman Development
and Pipeline Replacement Projecr -4(PRP-4)
19 DECLARATION: I hereby declare that the particulars given above are correct to the best of my
knowledge and belief. I further declare that my pass issued by ONGC security section will be
surrendered to the 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, I will immediately
report the matter to the police and produce the FIR in original to security section.

Countersigned by the Contractor Signature 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 the
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 Police Clearance Certificate in original.

Date:
Countersigned by Project In Charge of ONGC
(With office seal)

OFFICE USE
Pass No.

Issue Date: Valid Upto:

Signature of CIC