ICTT VALLARPADAM/SPECIAL ECONOMIC ZONE
India Gateway Terminal Private Limited, DP World Cochin.
ACCREDITATION FORM FOR EMPLOYEES/CONTRACT EMPLOYEES/PORT USERS
a) Name of the Applicant with initials :______
b) Name of Father/Husband : ______
c) Date of Birth : ______
d) Age : ______
e) Blood Group : ______
f) Identification Marks : ______
g) Nationality : ______
h) Agency/Department : ______
i) Designation : ______
j) ID Number(To be filled by IGTPL) : ______
k) Number and date of the certificate of safety induction (Validity -1 year from the date of last safety induction) :______
( Copy of the safety induction card should be attached)
l) Permanent Residential Address with Pin Code : ______
m) Present Residential Address with Pin Code :______
n) Number and date of Police Clearance Certificate (PCC)/Passport obtained within the last one year(Original or copy of PCC or copy of Passport should be attached) : ______
o) Number and date of a valid Photo ID card ( i.e. Driving License/Passport/ Electoral ID /Adhar Card)
(Copy of the ID Card Should be attached) : ______
P) Telephone number ( Home & personal) :______
q) Signature of the Applicant :______
I/We hereby declare that all the information furnished above is true. Further I/We hereby undertake the full responsibility for ensuring good conduct of the above person in the Terminal premises and in the event of any misuse of Passes, action as deemed fit including cancellation of registration can be taken up by the Terminal authorities. I/We undertake to return the original pass to IGTPL in the event of the above applicant leaving the employment of our organization.
Place:
Date: Stamp/Seal of Company Name & Signature of Authorized Signatory.
RECOMMENDATION OF THE CONCERNED HEAD OF THE DEPARTMENTS OF DP WORLD
1) HUMAN CAPITAL/OPERATIONS/ENGINEERING/IT
2) HSE
3) SECURITY HEAD