Private & Confidential

EMPLOYMENT APPLICATION FORM

Please attach
photo here
4cm x 6cm

To: Human Resource Department

Position applied for:

How did you learn about this vacancy:

Section A : Personal Information

MIFTAHUL ULUM
Full Name (capital letter): __________________________________________________ Sex: Male/Female

Date of Birth: Februari 19, 1976

________________________ Kendal
Place of Birth: _______________________________

Religion Islam
______________________________________________________________________

Full Address: Pondok Sirnabaya Indah Blok A no. 1 RT 008/005 Sirnabaya. Karawang
_____________________________________________________________________

Contact Number: 085288601979

________________________ Hand Phone: _______________________________

Email Address: miftahul1977@gmail.com

_____________________________________________________________________

ID Card Number: 3215011902760004

f _______________________ 17-12-2015
Issued by: _________________ on:_____________

Passport Number: ________________________ Issued by: _________________ on:_____________

Marital Status: Married

________________________ 3 person
No. of Children: _____________________________

Family (including mother, father, brother, sister, spouse & children if any)

Name Relationship Date of Birth Occupation Company

Kanin Father - -
Aisyah Mother - -
Ahmad Zamroni Brother businessman -
Nurwahidah Sister - -

List two persons as your emergency contact.

Name Relationship Telephone Mobile Address

Dessy Herliani wife 082114207823 Karawang

Section B : Education**

List below your last attendance at University/College/School

Institution(s) From Year to Year Place Qualification

Obtained
Singaperbangsa University 1998 - 2004 Karawang Graduated
STM N Kendal 1993 - 1996 Kendal Pass
SPM N 1 Kendal 1990 -1993 Kendal Pass
SD N Bandengan 1 1983 - 1989 Kendal Pass
*) pick one by crossing the unnecessary information / **) Please attach certified copies of your certificates

Section C : Employment History

Provide information for the last 10 years, starting with the most recent employment. If space
provided is insufficient, please attach separate sheet.
Company From To Position(s) Held Last Salary
(MM / YR) (MM / YR)
1
PT. Onamba Indonesia June 2014 Present Personnel & GA Head IDR 13.000.000
Reasons for Leaving:

Duties/Responsibilities:

Manage and control Personnel and General Affairs departement's activities

May we contact this current / previous employer? YES / NO

If yes, please provide name and contact number.
If not, please explain why. Firman Hidayat 081316546191
2
PT. Asia Pacific Fibers, Tbk Oct 1996 June 2014 HRD Ass. Manager IDR 7.500.000
Got better salary
Reasons for Leaving:

Duties/Responsibilities:

Manage personnal matters example :HRIS, training & development, Absenteeism,

Industrial Relation,Health Insurance etc

May we contact this current / previous employer? YES / NO

If yes, please provide name and contact number.
If not, please explain why. Ujang Sarpendi 083814368272
3

Reasons for Leaving:

Duties/Responsibilities :

May we contact this current / previous employer? YES / NO

If yes, please provide name and contact number.
If not, please explain why.
4

Reasons for Leaving:

Duties/Responsibilities

May we contact this current / previous employer? YES / NO

If yes, please provide name and contact number.
If not, please explain why.

Section D: Skills and Training

List other skills or training that support this application

Skill / Training Course Institution Certification / Year

Proficiency
MSDM for beginners profesional HRD Club Certificate of attendance 2014
HR Brotherhood super camp HRD Forum Certificate of attendance 2014
OD Specialist program Value Consult Certificate of competence 2012
Supervisory Management SIS Consulting Certificate of attendance 2012
English Business Course Global Education Level 1 2012

Section E: Languages

Language Spoken* Written*

English Poor / Fair / Good Poor / Fair /Good

Poor / Fair / Good Poor / Fair / Good

Poor / Fair / Good Poor / Fair / Good

Section F: References
List two persons not related to you, who are familiar with your character, background or work
performance, which we may contact at any time.

Name: Firman Hidayat

_______________________________________ Contact No.: 081316546196
___________________________________
Address: PT. Onamba Indonesia
_______________________________________ Occupation: Production Manager
___________________________________
_______________________________________ Years Known: 2 years
___________________________________

Name: Ujang Sarpendi

_______________________________________ Contact No.: 083814368272
___________________________________
Address: PT. Asia Pacific Fibers
_______________________________________ Occupation: HRD
___________________________________
_______________________________________ Years Known: 10 years
___________________________________
Section G : Other

Expected salary : IDR 16.000.000

Estimated date of join : one month after notice

Section H : Declarations and Authorizations

THIS APPLICATION IS NOT COMPLETED UNTIL THE FOLLOWING STATEMENT HAS BEEN READ AND SIGNED.

Have you ever been convicted of a criminal offence anywhere in the world, excluding
convictions that have been set aside or quashed? If yes, please provide details below.
Disclosure of a criminal record will not necessarily disqualify you for employment. However
failure to disclose such information may result in disqualification of your application or dismissal
from employment at DHL.
Details: Yes No

Have you ever been dismissed or suspended from any position, or subject to internal disciplinary
action by any of your previous employers? If yes, please state where, when, and cause.
Details:

Yes No

Do you have any immediate family members working in this company? If yes, please state the
name of the employee, designation, and relation.
Details:

Yes No

I certify that all the information provided in this application is true, complete and correct to the best of my knowledge. I
understand that any false information or omission may lead to dismissal or disciplinary action.

I authorize DHL (and its parent, subsidiaries, affiliates or agents) to verify all information provided in this application,
including employment history, educational background and references.

I authorize my previous employers and references indicated above to release any information they may have about
me.

To the extent permissible under the law, I release DHL and all other persons, companies or organizations, from any and
all liability to me arising from providing or receiving such information relating to me. DHL will only use information
collected in connection with your employment with DHL.

MIFTAHUL ULUM Karawang, March 15, 2016

Signature Date

Thank you for completing our DHL Application Form

DHL- Supply Chain Indonesia
Graha Intirub Bussines Park Build, 1st floor
Jl.Cililitan Besar No. 454 East Jakarta 13650 INDONESIA
Tel +62 (0) 21 29379030 Fax +62 (0) 21 29379050
www.dhl.com