安全记录申请审核表.docx

安全记录申请审核表 I 基本信息 Basic Information 姓名 Name 国籍 Nationality 出生日期 Date of Birth 年Y 月M 日D 性别 Sex □男 Male □女 Female 出生地 Place of Birth 联系电话 Phone Number 通讯地址 Mailing Address 永久住址 Permanent Residence Address 执照编号 License No. 档案编号File No. 颁发日期Date of Issue 年Y 月M 日D 身份证明种类 Type of Identification Document □身份证 ID □其它 Others 身份证明编号 Identification Document No. 工作经历 Experience 起止年月 Period 在何地、何部门、任何职务 Location, Service Organization and Title II 雇主信息 Information of Employer 前雇主信息 Information of Former Employer 名称 Name 运行合格证编号 AOC Number 地址 Address 新雇主信息 Information of New Employer 名称 Name 运行合格证编号 AOC Number 地址 Address III 申请人声明 APPLICANTS STATEMENT 我保证上述填写内容属实，如有不实后果本人负责。 I hereby that all statements and answers provided by me on the form are complete and true to the best of my knowledge. 申请人签字 Signature of Applicant 日期 Date of Application 年Y 月M 日D IV 前雇主报告 Former Employers Report □训练和检查的记录 Training and Checking Records □事故、事故征候结论 Accidents, Incidents Conclusions □奖励和惩罚记录 Reward and Punishment Records 上述记录副本已交予申请人。A copy of these records have been handed over to the applicant. 负责人签字（盖章） Signature of Responsible Person（Stamp） 联系电话Phone No： 日期 Date 年Y 月M 日D V 新雇主报告 New Employers Report □训练和检查的记录 Training and Checking Records □事故、事故征候结论 Accidents, Incidents Conclusions □奖励和惩罚记录 Reward and Punishment Records 上述记录副本已从申请人处收到。Has received a copy of the recording from the applicant □申请人执照信息 The applicants license information □执照信息附后License information attached □申请人的行政处罚摘要 Summary of the applicants administrative penalties □无 Naught □ 处罚信息附后 Penalties’ information attached □申请人当前扣分信息及说明 Applicant current deduction information and instructions_____________________________________________________________________。 □申请人当前扣分值 The current point of the applicant__________。 上述记录已从局方处收到。The record has been received from the administration 监察员签字Signature of Inspector： 年Y 月M 日D 经评估，我