EMPLOYMENT APPLICATION FORM

POSITION APPLICATION

1. POSITION APPLIED : perawat anestesi DATE OF INTERVIEW 11-Dec-20

2. HOW DID YOU FIND THIS VACANCY ?

LinkedIn Recruitment Agency/Headhunter Direct Application Others, please mention ____________

Facebook Jobstreet Staff Referral

PERSONAL DATA
1. FULL NAME Ficky Muhammad haryudi
2. SEX laki laki
3. PLACE DATE OF BIRTH Pandeglang
4. DATE OF BIRTH 12/1/1991
5. MARITAL STATUS menikah
6. RELIGION Islam
7. NATIONALITY Indonesia
8. ID CARD/PASSPORT NUMBER 3602150112910000
9. NPWP NUMBER 808334536419000
10. SOCIAL SECURITY NUMBER (BPJS KETENAGAKERJAAN)
11. CURRENT ADDRESS jl.salemba bluntas gang H.murtado 8 no.A696

12. PERMANENT ADDRESS (AS PER ID CARD) Kp.pasir degung, kec.warunggunung, kab.lebak, prov.banten

13. CONTACT NUMBER MOBILE 1 082298714364

MOBILE 2
RESIDENCE
14. EMAIL ryuki.magician@gmail.com

15. SOCIAL MEDIA LINKEDIN

FACEBOOK Ficky Haryudi
INSTAGRAM ficky_haryudi
TWITTER

FAMILY INFORMATION (for married individual, please fill in spouse & children data)
No Name Sex Relationship Education/ Occupation/ Company
1 intan lauwanda perempuan istri S2/Guru/ SMPN 6 depok

PARENTS AND RELATIVES DATA (for single individual, please fill in family members information)
No Name of Parents and Relatives Sex Relationship Date of Birth City Education/ Occupation
1 duddi saprudi laki laki ayah kandung 6/7/1960 pandeglang SMA/Wiraswasta
2 rosikah perempuan ibu kandung 10/9/1965 pandeglang S1/guru
3 ficky muhamad haryudi laki laki anak pertama 1/12/1991 pandeglang S1/perawat
4 fifi fatmawati rahayu perempuan anak kedua 9/1/1997 pandeglang S1/perawat
5 arya cembawan wijaksana laki laki anak ketiga 10/4/2003 pandeglang kuliah/pelajar

EMERGENCY CONTACT
No Name Relationship Address Phone Number(s)

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 1

 1 intan lauwanda istri jl.program IVB pancoran mas depok 8979996946

FORMAL EDUCATION
Qualification
No School/ Institution City Year of Graduation Major Obtained GPA
1 akademi keperawatan yatna yuana lebak banten 2013 keperawatan keperawatan 3.29
2 universitas esa unggul jakarta barat 2019 kesehatan masyarakat K3 3.02

LANGUAGE
No Language Spoken Written Reading
1 inggris moderate moderate moderate (Low/ Moderate/ High)
(Low/ Moderate/ High)
(Low/ Moderate/ High)

PROFESSIONAL LICENSES OR CERTIFICATION

No Name of Certification Name of Institution Years Obtained
1 BTCLS/BCLS pro emergency 2017
2 Anastesi RSUP.dr.Sardjito Yogjakarta 2017

WORK EXPERIENCE
Current Company
rumah sakit royal progress
Company Name
Company Address Sunter Paradise 1, Jl. Danau Sunter Utara, RT.6/RW.12, Sunter Agung, Tj. Priok, Kota Jkt Utara, Daerah Khusus Ibukota Jakarta 14350
Latest Position
perawat anastesi

Date (DD/MM/YYYY) Start Date 2020 End Date sekarang

Starting Salary 8000000

Latest Salary 8500000

Reason for leaving mencari pengalaman yg lebih baik

021-6400261
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why

Achievement(s)

Previous Company
rumah sakit sint carolus jakarta pusat
Company Name
Company Address jl.salemba raya no.41 jakarta pusat
Latest Position
perawat anastesi

Date (DD/MM/YYYY) Start Date 2013 End Date 01-Sep-18

Starting Salary 4500000

Latest Salary 6000000

Reason for leaving menyelesaikan skripsi karena sedang kuliah

021-3904441
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why

Achievement(s)

menjadi asisten dokter anastesi konsultan anastesi nyeri, dan regional.

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 2

Previous Company

Company Name
Company Address
Latest Position

Date (DD/MM/YYYY) Start Date End Date

Starting Salary
Latest Salary

Reason for leaving

May we contact this current/ previous employer directly?

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

Achievement(s)

ORGANIZATION STRUCTURE
(please draw organization structure showing your position in your current company)
kepala anastesi

dokter anastesi perawat anastesi

saya

REFERENCES
List two person NOT related to you, who are familiar with your character, background or work performance (preferably your direct supervisor)

Name : indah Contact No : 81299065328

Company : Job Position : perawat

Years Known :
Relationship : teman

Name : Contact No :
Company : Job Position :

Years Known :
Relationship :

CURRENT DETAILS OF SALARY AND BENEFITS

1. Monthly basic salary gross 8000000 IDR
2. Eligible for over time ? yes ( Yes / No )
If yes, monthly average ?
3. Allowances
Meal 2000000
Transportation 800000 IDR
Phone/ Handphone 300000 IDR
Others IDR
4. Loan facilities Type of Loan Housing Car Personal
Outstanding Amount Max Limit
Interest per Year % Outstanding Period (months/ years)
Repayment Methods (months/ years)
5. Annual Leave 100000 (Days)
6. Annual Bonus :
THR (Festive Allowance) 9000000 IDR
Performance Bonus IDR
Others, please explain IDR

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 3

7. Medical Benefits Cashless Reimburstment
Out Patients (Per Year) IDR
In Patients (Room & Board) IDR
8. Life Insurance 80000 IDR
9. Other Benefits, Please Explain: BPJS kesehatan dan kenagakerjaan

COMPENSATION BENEFIT EXPECTATION & COMMENCEMENT

1. Monthly salary (Gross) 9500000 IDR
2. Benefits / Others
3. If you are offered employment with us 1 januari 2021

when can you start work (or notice period) ?

DECLARATIONS AND AUTHORIZATIONS

1. Do you have any family members; as an employee, who working in this company? (Yes/ No)
If yes, please state the name of the employee, designation and relation. yes, yohana dan indah mayapada kuningan

2. Have you ever been dismissed or suspended from any position, or subject to internal disciplinary action by any of your
previous employers? (Yes/ No) No
If yes, please state where, when and cause

3. Have you ever been convicted of a criminal offence anywhere in the world, excluding convictions that have been set aside
or quashed? (Yes /No) No
If yes, please provide details.

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 of dismissal from employment at MAYAPADAHEALTHCARE GROUP
4. Have you ever apply/ work in MAYAPADA HEALTHCARE GROUP? (choose one) (Yes/ No) No
If yes, When ? For position ?
Where Last selection stage (for apply)

5. Are you currently holding any position in any political party or a candidate for any political office?
If yes, please provide the detail of position and political party and your joining date to that political party and the position that you are running for as candidate.

6. Is there any member of your immediate family an official or any government agency, an employee of any government agency,
an official of political party, or a candidate for political office? No
If yes, please states the detail of the name, position/office held and the family relationship. Immediate family means husband, wife, children, mother, father, siblings.

7. Do you have any other job or business activities outside the current employment? No
If yes, please provide the detail including name of enterprise, type of business, position and starting year of the position.

I certify that all the information provided on this application is true and complete to the best of my knowledge.
I understand that any false information or omission may lead to disciplinary action or summary dismissal without any compensation.
I authorize MAYAPADA HEALTHCARE GROUP 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.
MAYAPADA HEALTHCARE GROUP will only use information collected in connection with my employment with MAYAPADA HEALTHCARE GROUP.

Signature & Name

To the extent required by law, you may request to review and correct personal data through the HR Department.

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 4