Background Check Form

Note: The boxes marked by (*) are mandatory for filling.

PHOTO Please indicate whether you are a new employee or a current employee
New Employee: use this form to provide information for Terra Avia HR and Aviation
Security Department.
Current Employees: use this form to change name and identity information. If you are
changing your personal data you have to present a legal document.
Personal data:
Full Name*: YUSTINA YEKTI DWI PRAMAYANI

Marital status: MARRIED Maiden Name (completed by Women):

Date of Birth*: Place of birth*: Nationality: Gender: M F

13th February 1971 CIMAHI, WEST JAVA INDONESIAN
Actual residence*:
JL. KEBUN RUMPUT 1 NO. K-2 KPAD CIMAHI 40521 WEST JAVA
Place of residence during the previous five years:
JL. KEBUN RUMPUT 1 NO. K-2 KPAD CIMAHI, WEST JAVA
Phone No: Email:
082130996206 / 0817221695 / +6222 - 6642903 yustinapramayani@gmail.com

Education*:
Highest Education Level: Highest Degree:
UNIVERSITY BACHELOR
Date Acquired: Institution Name and Address:
9th of March 2012 IKIP SILIWANGI BANDUNG
Trainings and additional education for the last five years:
Dates Name of training center Address: Qualification

20th 25 th Oct 2015 Training BNSP-LSP AVIASI Jl. Setiabudhi Bandung Pass Assessor
INDONESIA

5th-6th of March 2018 Pearsen UK Event Hotel Mercure Bandung West Java Pass

Initial Training of Terra Avia Airlines Kuala Lumpur Malaysia MAS

12th - 16th of July 2017 MAS Kuala Lumpur Malaysia BOEING 747-400-RATED

Avia Terra Halim Perdana Kusuma Airport

6th-9th Nov 2017 Jakarta Pass TOT

15th Apr -05 May GITC Cengkareng Duri Kosambi Cengkareng

2013 Pass EASA COURSE

Work experience*:
Please provide the following information regarding your previous employers during the last five years.
Dates Name and address of employer Occupation or position held Tel No

2014 Garuda Indonesia Airlines Cabin Crew Hajj and Umroh +6221-8092130

2015 Garuda Indonesia Airlines +6221-8092130

Cabin Crew Hajj and Umroh

2016 Jogja Flight Training Center

Teacher 081332492789

2017 - Present Terra AVIA Airlines (Hajj Season Project) Cabin Crew

Personal references:
Please provide the contact details of two your personal references
Name: Miss Yuliana Kristi Relationship:
Sister
Address: Phone:
Perumahan Beverly Green Avenue No.16 Batam 081270173189
Name: Relationship:
Indri Maria Marciana Sister
Address: Phone:
Jl. Kebun Rumput 1 No. K-2 Cimahi +628131291712/+6222-6642903
 Criminal history records*
If you have any criminal history in all states of residence during at least the preceding five years, please provide the details
related to date or period, the type of conviction, criminal offence, and arrest.

If you are in possession of driving license, please provide the below details:
License Nr. Date of issue Issued by Valid until

I hereby declare the following:

- that the information presented in this Background Check Form and the attached documents are complete and
accurate;
- accept that any misrepresentation of the facts is grounds for refusal of employment and release of the employment
contract;
- I have no criminal convictions, and I will immediately inform the employer in case of any changes related to the
data and information presented in this declaration during the employment contract;
- that the employer has the right to request from the applicant any additional documents and information for the
purpose of verification and confirmation;
- authorize for approaches to be made, as appropriate, to any educational organization, previous employers,
Government agencies, personal references possessing information about me to provide the authorized
representatives of Terra Avia, any kind of information that they hold, regarding to any matter related to the
verification of the information;
- accept that my background check, including criminal history record will be performed.

I hereby confirm that my answers are true and complete to the best of my knowledge. I understand that false or
misleading information in my profile and interview may result in my release.

Signature of the Applicant________________________ Date______________________

Recommendations:
(have to be filled by the responsible person of Terra Avia)

Signature_____________________________ Date______________