employment application

personal data
name : Felixia Febriane Nick name: Feli, Feliz

home address : Jl. Taman Jimbaran VII No.260A, Jimbaran, Kuta Selatan, Badung

telephone : 9E+10 felixiafebriane@gmail.com

emali :

Instagram / FB : #NAME?

marital status ( • ) single ( ) married ( ) widowed ( ) divorced

place and date of birth Medan, 5th February 2002 Blood group : A

religion Buddha height : 155 cm weight : 40 kg

position applied for Graphic Designer expected salary : Around Rp. 2.000.000,-

second choice expected salary :

where did you hear about the job posting? Instagram

education
from
name of school or university to year certificate obtained or highest standard passed
year
secondary school SMP Swasta Wage Rudolf Supratman 2 Medan 2016 2018
senior high school SMA Swasta Wage Rudolf Supratman 2 Medan 2018 2020
Diploma D1 New Media College Bali 2021 2022
University

other

Workshop/Seminar/Training Fasilitator
1

3
languages understanding speaking reading writing
good fair poor good fair poor good fair poor good fair poor

indonesian ✓ ✓ ✓ ✓
english ✓ ✓ ✓ ✓

Others Mandarin ✓ ✓ ✓ ✓
employment record ( list present job first )

1 company or firm : Alca Art Installation address : Jl. Taman Baruna No. 2

position : Administration from : Oct-20 to : May-21 last salary : Rp. 1.500.000,-

reason for leaving : Found another job

2 company or firm : Balonku Babyshop address : Jl. By Pass Ngurah Rai, Nusa Dua, Mumbul

position : E-Commerce Staff from : Jun-21 to : Sep-21 last salary : Around Rp. 2.000.000

reason for leaving : start to school and can't working shift

3 company or firm : Alca Art Installation address : Jl. Taman Baruna No.2

position : Administration from : Oct-21 to : Jan-22 last salary : Rp. 1.000.000,-

reason for leaving : Only part time for looking for another job that suit my skill
4 company or firm : address :

position : from : to : last salary :

reason for leaving :

 Please state your life vision & mission

please describe your position including your superior/your staff at below colum

please explain if any other activities involved in organization

name of organization : field : position : length :

family record
spouse
name : date of birth : occupation :

children
name ( m / f ) : dob : name ( m / f ) : dob :
name ( m / f ) : dob : name ( m / f ) : dob :

parents, brothers and sisters

name relationship age address occupation

in case of emergency
person to contact : relationship :

address : phone no :

mark with an " x " no yes If so, give particulars

1 have you ever been dismissed from any employment because of misconduct
or unsatisfactory performance ?
2 have you ever been arrested or convicted of crime ?
3 may an inquiry be made of your present employer regarding your quaifications
and character ?
4 do you have any physical injuries / disability that may affect your work ?
declaration
i certify that to the best of my knowledge, the foregoing statements and medical history information given by me are true and correct.
i understand that if I am employed, any misrepresentation or omission by me here in will be sufficient cause for dismissal from the
service of this company without notice or payment in lieu of notice. after successfully passing the initial interview,
employment will be subject to the result of the medical examination and second interview.

_____________________________ date :
applicant's signature
 for official use only
remarks by interviewer (s)
rating : 1. outstanding 2. excellent 3. good 4. fair 5. poor
first interview second interview Third interview
rating remarks rating remarks rating remarks
Appearance
personality
communication ability
education
english comprehension
job knowledge
job interest
self confidence
related experience
technical
maturity
General Attitude

suitable/not suitable

reccomended other position

interviewed by: interviewed by: interviewed by:

date : date : date :

Reference Check
Company PIC Comment

acceptance
Position Dept Division Start Join

Form HRD