A) POSITION APPLIED FOR Pengurus (Kerjaya di Pusat Internet 1Malaysia Negeri Perak)

Vacancy known from Advertisement Website Newspaper Friends Others:_____________________

Place of Birth: Kuala Kangsar
Marital Status : Single Married Divorced Separated Widowed
Bank: Driving License: Yes No ; Class: A / B / C / D
To
No
1
2
3
Page 1 of 3
Year
EMPLOYMENT APPLICATION FORM
Religion: Islam Race:Malay
Incom Tax No:
Qualifications Attained*
(Please attached copy of certificates)
C) EDUCATION BACKGROUND (List School,Institutions and Universities attended)
E) SKILLS (Please tick at the specified column)
Good Fair
B) PERSONAL DETAILS
Full Name (as per NRIC) : Mohd Juzaili Hasrul Fitri B. Amir Hashim
Siblings:
Permanent Address: No.3 Persiaran Jelapang 19B,
Schools / Institutions / Universities
Correspondence Address:
Age: 31 years
Acc. No:
Height/Weight:185_cm/ 68kg
EPF No:
Sex: Male Female
SOCSO No:
Date of Birth: 07 July 1983
Written & Spoken
D) LANGUAGE PROFICIENCY (Please tick at the specified column)
Fluent
Location
From
F) OTHER QUALIFICATIONS /COURSES ATTENDED
Year Name of Course Institution/College/University
Advance Moderate Basic (Computer/Professional/Others)
Please read the instruction cafefully:
1. This form is to be completed before interview session.
2. Do not leave any item blank. If it is not applicable to you, please indicate "NA".
3. Please attached a copy of your IC or passport showing all relevant details.
4. Please attached photocopies of all your educational certificates & your comprehensive
resume during interview.
STRICTLY PRIVATE & CONFIDENTIAL
MSD GROUP OF COMPANIES
MSD Digital Intelligence Sdn Bhd (761551-T)
I-Fabulous Art Media & Event Sdn Bhd (904973-U)
Ingeniworks Sdn Bhd (934957-K)
Mutual Covergence Sdn Bhd (1000895-P)
Intelligence Net Care Sdn Bhd (709524-D)
Future Automation Services Sdn Bhd (762582-P)
Nilai Lavenda Sdn Bhd (916760-M)


No. 13 Jalan Puteri 5/20, Bandar Puteri,
47100 Puchong,
Selangor
Tel: 03-8068 2300 Fax: 03-8068 2400
Website: www.msd.net.my /
jobs.msd.net.my

Home Tel
Handphone
Email
: 05-526 7228
: 013-44 82228
: juzaili83@gmail.com
NRIC No
Passport No
Nationality
: 830707-08-6569
:
: Malaysia
AFFIX RECENT
PHOTOGRAPH
PASSPORT SIZE
G) FAMILY PARTICULARS
No Age Relationship Occupation Employer Name Contact No
1
2
3
4
5
6
H) SPOUSE PARTICULARS (if married)
Name : Date Married : No. of Children :
Employer Name & Address: Position :
Total Earning per month (RM) :
Office No. : Handphone No. :
To
Current Salary (RM) :
1
2
3 Expected Salary (RM): Allowances:
4
5
Last Drawn
To Salary (RM)
Page 2 of 3
K) RELATIVES / FRIENDS KNOWN IN THIS COMPANY
Reason for Leaving:
Company Name Telephone No.
_________________________
/month
Bonus:
Current Benefits:
Notice Period: Areasof Specialization / expertise
Name
I) PRESENT EMPLOYMENT
Year
From
Position Held
/month
Name of Company / Telephone No. Type of Industry/Business
Year
From
J) PAST EMPLOYMENT
Reason for leaving
Others; please specify:
_________________________
Position Held
No
1
2
No
1
2
No Name Contact No Period Known
1
2
Page 3 of 3
Name
Occupation Address
Period Known
2
N) OTHER RELEVANT INFORMATIONS (Have you ; if Yes please provide details)
Position Relationship
Yes No (If Yes please specify)
9
8
7
3 Ever been hospitalised?
Ever applied to this company or any of its subsidiaries?
Yes No (If Yes please specify)
1
6
Any friends or relatives working in this company or its subsidiaries?
Yes No (If Yes please specify)
Ever held any responsible position in a club, trade union or associations?
M) REFERENCES
Signature
Date:
5
4
DECLARATION
Yes No (If Yes please specify)
Do you own a vehicle?
Ever been a bankrupt?
Yes No (If Yes please specify)
Ever been convicted of a criminal offence?
Yes No (If Yes please specify)
Any physical disability or handicap?
Suffered from any major/long illness and/or drug additions?
Yes No (If Yes please specify)
Yes No (If Yes please specify)
Yes No (If Yes please specify)
L) EMERGENCY CONTACT
Name Relationship Address Contact No.
I declare that the information given above is to the best of my belief, true and
correct and that i have not suppressed any fact. I understand that any
mispresentation or falisification of any fact will be sufficient cause for the
cancellation of consideration for employment or immediate termination (if i
have been employed).