Entity’s Name

Entity Name in Arabic

Entity Name in English

Entity Activity Type

Entity Commercial License /Professional License

Commercial License/Professional License No.

Commercial License/Professional License copy attached

Entity Address

Telephone No.

P.O. Box

Email

Authorized Person Contact Information

Name

Occupation

Telephone No.

Email

Al Adaa Registration Number

OSHMS Approval Certificate Issued by OSHAD

Certificate No.

Certificate Issuance Date

Last External Audit Findings

Form F submittal for Last 2 Years

No. of Minor NCRs

No. of Major NCRs

HSE Violations Issued by ADM in all Entity’s Projects during the previous two years

No. of Violations

Serious Incidents occurred during the previous two years in the Entity

No. of Serious Incidents

Incidents Forms G & G1 submitted regularly in Al Adaa

OSHMS Performance Quarterly Reports (From E) submitted regularly in Al Adaa

Occupational Safety & Health Practitioners in the Entity with grade (A) of Qudorat

No. of Practitioners

Qudorat registration cards copies attached

General Requirement

1- Attachments files shall be submitted in PDF format.

2- Each file capacity is 2 MB