APPLICANT NAME: Rizky Kurnia DATE OF APPLICATION: 22 May 2021

APPLICATION FORM TO:

Position Applied : 1. Field Service Engineer

2.
PHOTO
4 x 6 cm
Notes:
a. Write in block letters.
b. PT. Magnus Indo Medika will keep all information received strickly confidential.
c. PT. Magnus Indo Medika will randomly check the
information provided, Applicant is therefore advised to
be accurate and factual.

A. PERSONAL DATA

Full name : RIZKY KURNIA

Place/Date of Birth :
Jakarta, 29 May 1996 Age: 25 √ Male Female

Height 170 cm Religion Islam Marital Status √ Single Widow

Weight 63 kg Nationality Indonesia Married Divorced

Address : Jl Pedongkelan Depan RT 002/015 No.130, Kapuk (Temporary/Permanent)

Cengkareng, Jakarta Barat, DKI Jakarta Telp.: 085882784911

Address outside Jakarta :

Telp.:

A √ C
ID Number/KTP : 3173012905960002 Driving License:

The house you currently live in

Own √Parents Relatives

Lease Rent / Cost Others

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 Do you have a car/motorcycle? (please state the brand and type) :

Motor cycle Vario

Own √ Parents Others

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B. MORE ABOUT YOU: FAMILY

FAMILY BACKROUND

Family Latest employment

Name M/F Age Education Remarks
Relationship Position Company
Father SULISTIYO M 62 SLTA Staff

Mother SRI LESTARI F 52 SLTA

1st Child RIZKY KURNIA M 24 D III

2nd Child RAGIL RAHMA FAUZIAH F 17 SMK

3rd Child
4th Child
5th Child
6th Child
7th Child

OWN FAMILY

Family Name M/F Latest employment Remarks

Age Education
Relationship Position Company
Wife/Husband
1st Child
2nd Child
3rd Child
4th Child

Do you any other dependence besides your spouse (wife) and children? (If yes, please who and how many)

C. MORE ABOUT YOU: SPARE TIME

1. State your main activities and hobbies during your spare time:
Jika saya mempunyai waktu luang saya membaca buku, dan melakukan rencana pekerjaan yang
akan dilakukan kedepan

2. How do you keep fit? How much sport do you do per week?
Menjaga Pola makan dan Pola istirahat, untuk olahraga tidak menentu

3. What cultural and/or artistic activities do you have? (Organization membership, Books, Movies, Music, Singing…)
saya membantu lingkungan dimana tempat saya tinggal seperti melakukan pendataan terhadap
warga dan sebagainya

4. How do you spend your holidays?

Saya menggunakan waktu liburan untuk istirahat dan dengan keluarga saya

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D. EDUCATIONAL BACKGROUND

1. FORMAL EDUCATION (Starting from Senior High/SMA/SMK)

Year Graduated
Degree Name of School/Universtity City Main Study/Major
Start End Not Graduated
SMA/SMK SMA Negeri 33 Jakarta Jakarta Barat IPS 2011 2014 Graduated
University Akademi Teknik Elektromedik Jakarta Timur DIII Teknik Elektromedik 2014 2017 Graduated
Andakara Jakarta

Rewards and Achievements received during the course of your formal studies (if any):
Saya pernah mendapatkan beasiswa dari Lembaga Van deventer maas Indonesia berupa uang tunai
selama 1 semester, dari semester 3 sampai 4

2. TRAINING & INFORMAL EDUCATION

Name of the course/training Institution's Name & Location Period and year Paid by:

3. OTHER SKILL/TALENT

State any other skill and/or talent that is relevant to give a better idea about your abilities.

E. EXPOSURE TO FOREIGN ENVIRONMENT

1. FOREIGN LANGUAGE ABILITY: Check your level of proficiency

Professional Elementary
Foreign Language Native/Bilingual Years of practice
proficiency proficiency

2. Travel/Stay/Study/Internship abroad (from the most recent)

Year Country visited Length of stay Purpose of the visit Where did you stay? (hotel/friends/relatives…)

2018 Singapore 2 Week Technical Training Hotel

Defibrillator
2019 Singapore 3 Day Technical Training Hotel
Ventilator
2020 Nusa Tenggara Timur 2 Week Install, Uji Fungsi, Training Hotel
defibrillator dan ventilator

3. OTHER EXPERIENCES INVOLVING INTERACTION WITH FOREIGNERS

State any other experience that is relevant to give a better idea about your exposure to foreign companies/people.

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F. EMPLOYMENT HISTORY
Start with the most recent employment first (name and telephone number will be used randomly to request for
reference) For fresh graduate, list your internship and summer/temporary jobs
Employer name and address: Position title and duties, number of subordinates: Start date: End date:

Reason(s) for Leaving:

Sector of activity:
Last monthly salary: Supervisor: Telephone no.:
Employer name and address: Position title and duties, number of subordinates: Start date: End date:

Reason(s) for Leaving:

Sector of activity:
Last monthly salary: Supervisor: Telephone no.:
Employer name and address: Position title and duties, number of subordinates: Start date: End date:

Reason(s) for Leaving:

Sector of activity:
Last monthly salary: Supervisor: Telephone no.:
Employer name and address: Position title and duties, number of subordinates: Start date: End date:

Reason(s) for Leaving:

Sector of activity:
Last monthly salary: Supervisor: Telephone no.:

1. State your main achievements during your professional career:

Bisa keliling indonesia

2. State your best result in your last position:

Melakukan Service Defibrillator dan ventilator

3. Based on your experience: can you state what you do not like in a professional environment?
Saling menjatuhkan satu sama lain

4. Draw the Organizational Structure depicting your position in your last employment:

Manager Teknik

SuperVisor Teknik

Field Service Engineer

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G. ADDITIONAL INFORMATION

ANSWERS
QUESTIONS
Yes No Remarks/Comments

Relation with PT. Magnus Indo Medika

Have you ever applied to this group/company ? √

If yes,when and for what position?

√
Have you known Magnus before this contact?

√ Sangat baik
How have you heard about this company jobs opportunities?

Do you have any relatives/family members working in this group/company? √

If so, please state name, position and relationship

Do you have any friends/Acquaintance working in this group/company? √ Nama : Irna Aulia, Product Spesialis, teman satu
If so, please state name of each of them and relationship
kampus

General availability for the employment:

√
Do you have any medical or psychological condition that we should be aware of?
√
Do you have any criminal record?

Do you have any side business or part-time job? √

If yes can you explain how much time it takes you per week?

Should you be accepted in PT. Magnus Indo Medika

√
Are you willing to travel to outside Jakarta? Including overnight in other city?

Are you willing to be posted outside Jakarta? √

State the city and/or province you would consider

How soon can you join?

Can you detail for us your current employment conditions : salary and other
benefits:
JUNI 2021
Di sini mendapatkan gaji pokok, uang transport, uang
pulsa, insentif setiap melakukan pemasangan alat, bpjs
ketenagakerjaan, bpjs kesehatan

Rp. 6.500.000
State amount of salary expected? (gross)

I hereby certify that all the information provided by me on this application form are true and correct.
I understand and agree that Magnus verify part or all of these information during the process of my application.

Jakarta, 22 Mei 2021

Rizky Kurnia

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