Form A1 - Identification of Entity Main Activity

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ADOSH -SF – Forms
Form A1 – Identification of Entity Main Activity - Version 4.0 – 15th July 2024 Page 1 of 3
Form A1
General Information
Name of Entity:
Number of Employees:
Entity Offices / Branches in
Abu Dhabi Emirate:
 Abu Dhabi Total No. of Offices / Branches:
 Al Ain
 Western Region
Other Sites / Projects
Operating Under this Entity:
Contact of Head Office within
Abu Dhabi Emirate:
Telephone No.: E-mail Address:
Fax No.: P.O. Box:
Authorized Person providing
Information:
Name:
Position:
Telephone No.: E-mail Address:
Fax No. : P.O. Box :
Entity Activities
Trade License No.
(Attach copy)
Activity/Activities as specified
in the trade license:
Title of Activity Indicate if operational
(yes/No)
Main Operational Activity /
Activities of the Entity
Other licenses issued for the
Entity (Attach copies)
1………………………………………………………………………………………
2………………………………………………………………………………………
3………………………………………………………………………………………

ADOSH -SF – Forms
Form A1 – Identification of Entity Main Activity - Version 4.0 – 15th July 2024 Page 2 of 3
Form A1
Indicate the sector that your
activities are related to:
 Energy  Transport  Tourism
 Construction  Industry  Food
 Health  Waste  Commercial
 Education  Other (specify):
Remarks / Other Information
Declaration
I declare that all information provided in this document is true, correct and complete.
Signature of the
Authorized
Person
providing the
Information:
Official
Stamp :
Date :
(DD/MM/YYYY) _____/_____/_____
Official Use
Part A – To Be Filled by the SRA
Meeting with / site visit to the entity:
 Not Required
 Done: __ __ (Day) __ __ (Month) __ __ __ __ (Year)
Sector or sectors, that entity
activities fall under
 Energy  Transport  Tourism
 Construction  Industry  Food
 Health  Waste  Commercial
 Education  Other (specify):
Main Operational Activity /
Activities of the Entity that are
subject to ADOSH-SF:
Decision:
 Nominate entity within own sector.
 Entity needs to be nominated by (name SRA / Sector) _______________, because:
___________________________________________________________________________________________
 Refer entity to ADPHC for decision on the SRA to nominate, because:
___________________________________________________________________________________________
Date Entity Notified of SRA Decision: __ __ (Day) __ __ (Month) __ __ __ __ (Year)

ADOSH -SF – Forms
Form A1 – Identification of Entity Main Activity - Version 4.0 – 15th July 2024 Page 3 of 3
Form A1
Relevant Authority Stamp and
Authorized Signature Entered into Database by:
Name:
Signature:
Date: (DD/MM/YYYY) _____ / _____ / _____
Reviewed by:
Name:
Signature:
Date: (DD/MM/YYYY) _____ / _____ / _____
Part B – To Be Filled by ADPHC
Date Form A1 Received:
(DD/MM/YYYY) _____/_____/_____
Meeting Date:
(DD/MM/YYYY) _____/_____/_____
Sectors participating in the
Meeting
 Energy  Transport  Tourism
 Construction  Industry  Food
 Health  Waste  Commercial
 Education  Other (specify):
Decision:
 Entity needs to be nominated by (name SRA / Sector) _______________,:
Justification:____________________________________________________________________________________
_______
Date (DD/MM/YYYY):
Center Stamp and Authorized Signature