·APP~ICATION FORM

Formulir Lama.ran

1 Position Applied
.,
Posisiyang dilemut

Effective date

I. PERSONAL DATA
DATA PR/BAD/
M/F*
1. Full Name
NamaLmgkap
. P/W*

2. Place/Date of Birth

Tempat /Tanggal Labir

3. ID Card Number
NoKTP

4. Driving Licenses C. No.

A.No. B. No.
SIM

5. NPWP

6. Email Address

Alamat Email

7. Religion
.
Agama

8. Ethnicity

.Suku Bangsa

9. Marital Status

S talus Pemikahan.

10. Current Address (Alamat Tempat Tinssa! Saat Im) Home Address (Alamat Asa~

Home Number: Mobile Phone: Home Number: Mobile Phone:

Telepon Rumah Telepon Selular Telepon Rumah Tekpon S etutar

Status: Own / Parents / Contract, Board * Status: Own / Parents / Contract, Board *
l\fi!ik Sendiri / Milik Orang Tua / Kontrak, Sewa ~ Milik Sendiri / Mi1ik Orang Tua / Kontrak, Sewa *
*) Choose the item by delete the others!
Pifih salah satu item denoan menohatius tnliban lainnva!
 II. FAMILY BACKGROUND
LATAR BELA.KANG KELUARGA

Relation Name Birthday Latest Education Current Job

Nama Tg/Lahir Pendidikan Terakhir Pekerjaan

Hubungan .,
Spouse

Pasangan

Children
-------------------------------------------------------____. . +.------ -----+-------------------
Anak 2
--------------------------------------~---------- --------------~---------------------------
3
------------------ ----------1------------t------------------
4

2. Family Tree, Including You (Susunan KeluarJ,a, TermasukAnda)

Name Birthday Latest Education Current Job

Relation

Hubungan Nama Tgl Lahir Pendidikan Terakhir Pekeqaan

Father

Ayah
---------- .---------------------------------1-------------------------------------+--------------------------------------+------------------------------------------'
Mother

lbu

.. Brothers/Sisters 1

Saudara 2
~-------------------- -----+--------------------------------------1
3

---------- --------+----------------4----------
5

III. EDUCATIONAL BACKGROUND AND LANGUANGE COMPETENSCIES

LATAR BELA.KANG PEND/DI.KAN DAN KEMAMPUAN BERBAHASA

1. Formal Education

Pendidiean Formal
 Level
Tingkat
Scbool/JJniversity f Major
. From Month/Year Until
Month/Year
GPA
IPK
Sekolah/Perguruan Tinggi Jurusan Dari Bulan/Tahun
.. Sampai

Bulan/Tahun
..
-
High School

SUA

Diploma

Diploma .

Bachelor

S1

Master

S2

2. Non Formal Education (Include Course, Training, Seminar, etc)

Pendidiean Non Formal (termasuk Kursus, Pelatihan, Seminar, LJkakarya,d/0

Name of Coutee or Training Held by dd/mm/yy Notes

Nama Kursus atau Pe/atihan Penyelenggara tgl/bln/thn Keterangan

3. Please give· checklist ('{; based on your language competencies

Mohon beriean lam/a checklist {'I) sesuai dengan kemampuan berbabasa Anda

Foreign Language Competencies Spoken Written

Bahasa asing yang dikuasai Lisan Tulisan

English D Active D Passive D Active D Passive

Bahasa lnggris

Language ............ D Active D Passive D Active D Passive

Bahasa ................

Language ............ D Active D Passive D Active D Passive

[ Bahasa .

IV. ORGANIZATIONAL BACKGROUND AND ACHIEVEMENTS

LA TAR BELAKANG ORGAN/SAS/ DAN PRESTAS/

"
1. Social Activity

Aktivitas So.rial

Field of Organization Attendance Period Notes

Name of Organization

Nama Organisasi .. Bidang Periodc Kepesertaaa Keterangan

2. Awards

Penghargaan

Achievements Year Notes

Prestasi Tahun Keterangan

V. WORKING EXPERIENCE
PENGALAMAN KERJA

1. Please fill it descending, from your current/latest employment!

Mohan isi

dimulai danpeeerjaan terakhir!

1. Company name f

Nama Perusahaan '

Company Field
Bereerak: di Bidarur
Position
Jahatan
From (mm/yy) - Until (mm/yy):
Dari (Bln/Tbn) - Sampai (Bln/ Tbn) ••
Job Description
Gamharan Pekerjaan

..

Please describe rour current position. in organizational chart\ ORGANIZATION CliART

Mabon gambarkan posisi Anda saat ini dalam struletur organisasi! STRUKTUR ORGAN/SAS/
 2. Company name
Nama Perusabaan
r
.
Company Field
Bergerak di Bidane
Position Sallary:
Jabatan Gaji
From (mm/yy) - Until (mm/yy):
Dari (Bln/Thn) - Sampai (Bin/ Tbn): "
Reason to Leave
Alasau Berheati
3. Company name
Nama Perusahaan
Company Field
Berl(Crak di Bidan,e
Position Sallary:
fabatan Gaji
From (mm/yy) - Until (mm/yy):
Dari (Bln/Tbn) - Sampai (Bin/ Thn)
Reason to Leave
Alasan Berhenti
Note: You may add your work history by copy the box above and paste below!

Catalan: Anda dapat menambahkan rituaya: pekeryaan Anda dengan membuat kotakyang ban. di bawahnya!

2. Please mention your former supervisors during your work history above!

Sebutkan orang-orangyang pernab menjadi atasan dalam earier Anda dalam perusabaan di atasl

No. Name Position Company Contact Number

Nama Jabatan Perusabaan Nomor Knntak

1.

2.

3.

'

3. Have you ever made innovation or change during your work history? Please explain!

Pemahkah Anda melakukan pembabaruan / perubahan selama Anda bekerja? Jelaskan!

 VI. MEDICAL HISTORY "
RIWAYAT KESEHATAN

1. Please give checklist (-v) and notes, based on your Medical history!

Silahkan berikan tanda checklist ('/) clan keterangan sesuai dengan ruuayat eesebatan Anda!

,j Diseases Has been hospitalized at (dd/mm/yy) Notes

Pcnyekit -Pernah dirawat pada (tgl/bln/thn) Kei-era.ngan

Heart disease
D
Jantung

D Hypertension

Hipertensi

D Diabetes

Diabetes

D Hepatitis

I-Iepatitis

D Cancer
•
Kanker

D TBC

TBC

D Asthma-
'
Asma

D AIDS

AIDS

D Other Diseases

Penyakit lainnya
 VII. REFERENCES
REFERENSI

1. Please give names of colleagues for your references!

Silahkan tu/is nama kerabat untuk referensi anda!

Phone Number
Name

. No Telepon
Nama

Company
Position

Jabatan Perusahaan
.
Relation

Hubungan

Phone Number
Name

Na.ma No Telepon

Position Company

Jabatan Perosahaan

Relation

Hubungan

..
2. Please give names we can contact in an emergency situation!

Si/ahkan tu/is nama orangyang dapat dihubungi segera dalam keadaan mendesak/ daruratl

Name Name

Nama Name

Relation Relation

Hubungan Hubungan

Phone Number Phone Number

No. Telepon No Telepoa

Company car r
'
Fasilitas Kendaraan

Allowance: Meal

Tunjangan Makan Siang .,

Transport

Transportasi

Medical
..
Kesebatan

Holiday

mR .
Other

Lain-lain

Bonus

Bonus

Others

Lain-lain

I declare that all information given herein is true and correct. I understand that any misrepresentation or omission of facts will be
sufficient cause for cancellation of consideration for employment or dismissal from the Company's service if I have been employed.
Dmgan ini Sqya menyatakan babiua semua data yang Sqya tulis/ean diatas adalab benar. Soya menyadan bahwa ketidaijujuran mengenai data-data di
atas dapat mengakibat/ean pembatalan atau pemutusan hubungan kerja danpibae perusabaan.

Signature an<l name