EMPLOYMENT APPLICATION FORM

POSITION APPLICATION

1. POSITION APPLIED : NURSE DATE OF INTERVIEW 15 JUNI 2021

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 ABDUL ROHMAN
2. SEX MALE
3. PLACE DATE OF BIRTH JAKARTA
4. DATE OF BIRTH 22 MEI 1992
5. MARITAL STATUS single
6. RELIGION ISLAM
7. NATIONALITY INDONESIA
8. ID CARD/PASSPORT NUMBER 3172 0322 0592 1001
9. NPWP NUMBER 94 941 750 5-045 000
10. SOCIAL SECURITY NUMBER (BPJS KETENAGAKERJAAN) 2007 0166 259
11. CURRENT ADDRESS JL. KUBIS IV A NO. 4 RT 005/RW 005 PONDOK CABE ILIR, PAMULANG, TANGSEL

12. PERMANENT ADDRESS (AS PER ID CARD) KP WALANG RT 008/003 RAWA BADAK SELATAN, KOJA, JAKARTA UTARA

13. CONTACT NUMBER MOBILE 1 : 0812 9672 1637

MOBILE 2
RESIDENCE
14. EMAIL rahms155@gmail.com

15. SOCIAL MEDIA LINKEDIN

FACEBOOK
INSTAGRAM abdurrahman2235
TWITTER

FAMILY INFORMATION (for married individual, please fill in spouse & children data)
No Name Sex Relationship Education/ Occupation/ Company
1 M. djoko purwoko male father

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

EMERGENCY CONTACT
No Name Relationship Address Phone Number(s)

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 1

 1 joko purwoko father koja 81381381888

FORMAL EDUCATION
Qualification
No School/ Institution City Year of Graduation Major Obtained GPA
1 STIKES MADANI D.I YOGYAKARTA 2019 NURSING S1 NERS 3,63

LANGUAGE
No Language Spoken Written Reading
1 ENGLISH MODERATE MODERATE MODERATE (Low/ Moderate/ High)
2 ARAB MODERATE MODERATE MODERATE (Low/ Moderate/ High)
(Low/ Moderate/ High)

PROFESSIONAL LICENSES OR CERTIFICATION

No Name of Certification Name of Institution Years Obtained
1 PELATIHAN BTCLS 2019
PELATIHAN KEPERAWATAN INTENSIF
2 CARE UNIT HIPERCCI 2020
3 PELATIHAN HIPERKES HIPERKES 2021
WORKHSOP TATA LAKSANA
4 PULATKESDA DKI JAKARTA 2021
VAKSINASI COVID 19

WORK EXPERIENCE
Current Company
WISMA ATLET KEMAYORAN
Company Name
Company Address WISMA ATLET KEMAYORAN RT 13 RW 9 KB KOSONG, JAKARTA PUSAT
Latest Position
NURSE

Date (DD/MM/YYYY) Start Date Apr-20 End Date

Starting Salary Rp. 7.500.000

Latest Salary Rp. 7.500.000

Reason for leaving I WANT TO DEVELOPPATIENT CARE SKILLS

May we contact this current/ previous employer directly?

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

Achievement(s)

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)

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)

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

Name : Contact No :
Company : Job Position :

Years Known :
Relationship :

Name : Contact No :
Company : Job Position :

Years Known :
Relationship :

CURRENT DETAILS OF SALARY AND BENEFITS

1. Monthly basic salary gross 6.000.000 IDR
2. Eligible for over time ? ( Yes / No )
If yes, monthly average ?
3. Allowances
Meal Rp. 50.000
Transportation Rp. 75.000 IDR
Phone/ Handphone 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 12 (Days)
6. Annual Bonus :
THR (Festive Allowance) Rp. 6.000.000 IDR
Performance Bonus Rp. 2.000.000 IDR
Others, please explain IDR

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 3

7. Medical Benefits Cashless √ Reimburstment
Out Patients (Per Year) Rp. 4.000.000 IDR
In Patients (Room & Board) IDR
8. Life Insurance Rp. 6.000.000 IDR
9. Other Benefits, Please Explain:

COMPENSATION BENEFIT EXPECTATION & COMMENCEMENT

1. Monthly salary (Gross) IDR
2. Benefits / Others
3. If you are offered employment with us
1 Juli 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) NO
If yes, please state the name of the employee, designation and relation.

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.

ABDUL ROHMAN
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