APPLICATION FOR EMPLOYMENT

This Application will be kept strictly confidential, please fill in complete information, put N/A where it is not applicable and use capital letters

Position Applied for : Supervisor Clinic Expected Salary : 5.000.000

Personal Data

Date: Bandung, 22 Juni 2022

Name: Anggi Anggraeni

First Middle Last

Present address : KP. Cicango RT. 002 RW. 001 Desa Pangguh Kec. Ibun Kab. Bandung

Telephone : 085781189953 Date of Birth : 20 April 1992

Mobile Number : 085781189953 _ _ _ Place of Birth : Bandung

Email address: anggianggraeni.carrer@gmail.com _ _ Height: _ 155 cm | Weight: 49kg

Nationality __Indonesia
Marital Status:
ID Card No/ Passport No 3276056004920017
✔️ Single Married Separated Widowed
Issued By :
Spouse’s Name : _
Expiry Date : _
Date of Birth :: Marital Date:

Family Particular Occupation/Firm :

Father’s Name : Iyen Cahyawan
Address : _
Age : 55 Occupation : Buruh
__
Mother’s Name : Winda Winarti
Phone Number :
Age : 48 Occupation : Ibu rumah tangga

Address: KP. Cicango RT. 002 RW. 001 Desa Pangguh Kec. Ibun Kab. Mobile Number :
Bandung
st Child Name :
_

Phone Number : : _ 1
DoB : Sex : Male F emale

nd Child Name :
2
DoB : Sex : Male F emale
rd Child Name :

3
DoB : Sex : Male F ema

Educational Record

Educational Level Name and Address of From – To Certificate Major/Degree

School / College Year (Yes/No)

Primary

Secondary

Voc./Sr. High School

College/University
Others

Major Training Courses or Seminar Attended

Course/Topic Institute of Organizer Date of Training Certified Obtained

Address ; Jln Jepun Pipil, No. 11, Kertalangu, Denpasar Timur Phone : 62 361 4763669
 APPLICATION FOR EMPLOYMENT

Proficiency In Language

Please tick ‘√’ where applicable

Language Speak Read Written

Good Fair Poor Good Fair Poor Good Fair Poor

Indonesia

English

Others

Other Skill

Typing Mandarin Japanese English Fax Operation Copy Machine

Computer Program : Word Excel Power Point Page maker Others

Hotel Program : Fidelio Realta Power Pro VHP Other

Employment Record

Please list all employment, starting from most recent/current rmployment

Employment Date Company’s Name and Address Position Held Last Salary Reason for Leaving

From To

Can we contact your employer(s) : Yes No

Are You self employed : Yes No Current Salary : _ OTHERS (BONUS,

SERVICE CHARGE) :

Health

Yes
1. Have You had any serious illness or injury during the past 5 years? No

If Yes, please describe : ______________________________________________________________________________________

2. Do You have any physical handicaps, chronic diseases or other disabilities? Yes No

If Yes, please describe : _ _

_ _

2
Address ; Jln Jepun Pipil, No. 11, Kertalangu, Denpasar Timur
Phone : 62 361 4763669
 APPLICATION FOR EMPLOYMENT

3. Are You Smoking? Yes No

4. Do You have any Tatoo or Piercing ?

Yes No

If Yes, please describe : _ _ _

_ _

Miscellaneous

Ability to drive a Car vehicle : Motorcycle Other _

Driving license (If Any) : _ Type of Vehicle _ _

Kind : Yearly Permanent License No : _

Your interest in social and recreational activities :
Club or association you are a member of :

1. _ 2. _

Your Hobbies ________________________________________________________________________________

Additional information:

Have You ever charged or convicted of any criminal offence against the law?

Yes No If YES, describe Date, and Verdict : _ _

Nature of Offence : ____________________________________________________________________________________________

_ __ _
_
Please list relatives or friend currently employed in URBAN COMPANY (If any).

Name Position Relations

1. _ _ _ _

2. _ _ _ _
Please list contact in case of emergency:

Name : _ Relationship :

Address : Phone :

REFERENCES
Person of reference (Not a relative, former supervisor are
preferable)

Work Place
Name
Position
_ _ _

1.

3
Address ; Jln Jepun Pipil, No. 11, Kertalangu, Denpasar Timur
Phone : 62 361 4763669
 APPLICATION FOR EMPLOYMENT

_ _ _

2.

If you are accepted, what is your

notice period : _Days/month

I certify that all information provided in this application form is true and complete to the best of my knowledge. I understand that wilful misrepresentation and or false statement or omission of
facts will be adequate ground for dismissal .

Applicant’s Signature _ Date :

4
Address ; Jln Jepun Pipil, No. 11, Kertalangu, Denpasar Timur
Phone : 62 361 4763669