Chembond Water Technologies

To,
The Security In-charge (Via Business HR Tata Power, Haldia)
Tata Steel, HMC Division
Haldia: Purba Medinipur

Subject: Issue / Renew of gate pass against the Work Order No for nos.
Of workers for the period from to

Sir/Madam,

I/We is/are engaged as contractor in Tata power Haldia in

department for work/job. I/We therefore request for issuance / Renewal
of gate pass and hereby declare following from my/our end as true and best of my/our knowledge.

Name of Contractor
Address of the Contractor:
Email and Phone Number of Contractor:
Work Order Duration (Valid from and Valid Till):
Trade License Number:
Labour License Number:
PF Code:
ESI Code:
Department Signature Remarks

Reporting/User Department

Medical/Factory Medical Officer

Safety

Business HR

Security

Enclosure:

List of ESI PF Notice for Payslip Registers Medical Copy of

Workmen Payment Report Last Gate
in Pass
prescribed
format

Signature of Contractor’s Representative

Chembond Water Technologies Limited

(formerly Chembond Solenis Water Technologies Ltd)
EL-71 Mahape MIDC, Navi Mumbai 400710. INDIA
T: +91 22 39213000 - 03 ● F: +91 22 27681294
www.chembondwater.com
CIN: U24110MH1984PLC143564
 Chembond Water Technologies
Workmen Details – Part 1

S. Name ESI No PF No Date of Designation Current Gate

No. Birth Pass Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

Details of Workmen Engaged

Number of gate pass issued till Number of gate pass returned Number of Gate pass to be
date till date applied now

Contractor Declaration – I hereby declare that above specified information is/are true and as per
best of my knowledge.

Signature of Contractor’s Representative Verified by Business HR, Tata Power Haldia

Signature Signature

Date: Date:
Chembond Water Technologies Limited
(formerly Chembond Solenis Water Technologies Ltd)
EL-71 Mahape MIDC, Navi Mumbai 400710. INDIA
T: +91 22 39213000 - 03 ● F: +91 22 27681294
www.chembondwater.com
CIN: U24110MH1984PLC143564
 Chembond Water Technologies
Workmen Details – Part 2

S. Name Designation Age Proof of Identity Skill Set Affirmative

No. submitted Action
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Above details to be duly filled as per legends below –
1. Skill Sets – (i) Super Skilled, (ii) High Skilled, (iii) Skilled A, (iv) Skilled B, (v) Semi Skilled, (vi) Unskilled
2. Affirmative Action – (i) General, (ii) OBC, (iii) SC, (iv) ST]
3. Identity Proof – (i) Aadhaar Card, (ii) Voter Card, (iii) Driving License, (iv) Ration Card, (v) Pan Card, (vi)
Class 10th Marksheet
4. Age Proof – (i) Aadhar Card, (ii) Voter Card, (iii) Driving License, (iv) Ration Card, (v) Pan Card, (vi) Class
10th Marksheet
To verify details with respect to point no 3 & 4m copy of ID proof (self-attested) to be enclosed while applying
for gate pass.
Contractor Declaration – I hereby declare that above specified information is/are true and as per best of my
knowledge.

Signature of Contractor’s Representative Verified by Business HR, Tata Power Haldia

Signature Signature

Date: Date:
Chembond Water Technologies Limited
(formerly Chembond Solenis Water Technologies Ltd)
EL-71 Mahape MIDC, Navi Mumbai 400710. INDIA
T: +91 22 39213000 - 03 ● F: +91 22 27681294
www.chembondwater.com
CIN: U24110MH1984PLC143564