Name :

APPLICANTS FORM STATUS

Applicant is advised to complete this form directly from word software
application.
Name Joko Purnomo
Date of birth 16 December 1989
Education S1 Recent
Position applied CDP Photograp
for h
Present position
Source Upkk.ub.ac.id

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n

Date

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Strictly Confidential, Page 1 of 5

 Name :

Date

EMPLOYMENT APPLICATION
Position Applied CDP 2017
for

Name Purnomo Joko

Last name First name Middle name

Permanent Karang sari, sempu, Banyuwangi

Address
Ph - Cellular -
Ph#

E-mail Joko_purnomo_st@yahoo.com

Postal Address Griya Santha F.220 Malang

Ph 0812 5923 9098

Office Ph# Extension

#

Place, date of Banyuwangi, 16 December 1989 Se Male

birth

Religion Islam Indonesia 3510091612890001

ID#

Marital Status Married

Language English Speak* F Write* F

Bahasa Speak* E Write* E

Driving License # SIM. A/C Blood O+

T
y
p
e
A/C Jsostek
#

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 Name :

EDUCATION AND TRAINING

From To Highest Class/
Type of
Name of Institution M/Yr M/Yr Qualification
Education
Obtained
Secondary School 2005 2008 IPA
SMA Negeri 1
Genteng

2010 2015 Bachelor Degree

Tertiary School Brawijaya University
University

Vocational/
Professional/Traini
ng

EMPLOYMENT HISTORY (Start with your present employer and work back)
Name of From To Position Ending Reason for
Firm M/Yr M/Yr Start Ending Salary Leaving
PLN Area 1/201 4/201 staf staf - Internship
Malang 4 4
Brawijaya 7/201 6/201 Asistant Asistant - Dedication
University 2 4 Laboratori Laboratori
um um

*Please delete as appropriate

FAMILY STATUS (Spouse, Children)

Name M/F Date of Education Name of Firm
Birth
Spouse Dewi Sagita F 19-12-1989 S2
Child 1 Arduino AGP M 27-10-2016
Child 2
Child 3
Child 4

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 Name :

FAMILY STRUCTURE (Parent, Brother/Sister, Including you)

Name M/F Date of Education Name of Firm
Birth
Father Samsuri M 30-6-1937 SD
Mother Siti Saada F 2-2-1965 SD
Child 1 Ratna F 14-7-1987 S1
Wulandari
Child 2 Joko Purnomo M 16-12-1989 S1
Child 3 Indah Lestari F 20-7-2000 SMA
Child 4
Child 5
Child 6

REFERENCE (One who could be checked about you with your prior knowledge)
Name Yrs/Know Occupati Firms Name & Phone
n on Address
SOEPRAPTO

Hobbies, Interest Sports, technology

etc.

Have you applied for employment at AG Group No

before?
If yes, state the Date
position appli
ed

Salary Expected 7000000 Date 1 Mei 2017

Availa
ble

I here certify that the fore going statements are made truthfully and that the information is correct to the
best of my knowledge and belief. I understand that should I be appointed any misrepresentation on this
application is sufficient cause of dismissal. I also understand that employment at AGIT is contingent upon
satisfactory reports on a check of my references and a physical examination.

Date __8 April 2017_ Signed _Joko Purnomo ST_______

For Official Use Only

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 Name :

Employ
Reject ____________________ ______________________
Reverse for future openings Date HRD Manager

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