Page 1 of 5 Form No.

HRF01-002
PT Cosmic
Indonesia

PHOTO

Application For Employment

Post applied for :
Earliest date to
Salary Expected : Start employment :

I PERSONAL DETAILS
Full Name Place of birth
*Mr/Mrs

Aliases (if any) Date of birth

Address Citizenship

IC No.

NPWP No.

Religion

Office : Home: Dialect

Group

Pager : Handphone : Passport No. (if non-Citizen)

Marital Status : Date/Place of Issue

*Single/Married/Divorced/Widowed/Separated

Possess Driving Licence Yes No Email:

II FAMILY PARTICULARS (Please include all family members, including married ones)
Name Relationship Age Occupation Place of Occupation

If in case of emergency

Person to contact Contact No 1

Relationship Contact No 2

Address
 Page 2 of 5 Form No.HRF01-002
III EDUCATION (Please attach all relevant certificates, if requested)
NAME OF SCHOOL From To Highest Standard Passed

Primary

Secondary

Pre-University

University

Polytechnic

Vocational

Professional Institute

Others

Part-Time Courses
Studied Now

Part-Time Courses Which

You Intend To Study

Merit Awards Received Year:

IV EMPLOYMENT HISTORY (Please attach all relevant testimonials)

NAME OF COMPANY
(Begin with Present Employer) Position Held From To Basic Salary Allowance

Job Responsibilities

Job Responsibilities
 Page 3 of 5 Form No.HRF01-002
IV EMPLOYMENT HISTORY (Please attach all relevant testimonials) – continue
NAME OF COMPANY
(Begin with Present Employer) Position Held From To Basic Salary Allowance

Job Responsibilities

Have you worked in this Company before? Yes No

If “Yes” provide the following details.

Date joined : Position :

Department : Last Drawn Salary:

Have you been terminated/dismissed/suspended from the service of Yes No
any employer?

If yes, please give

details :

V ACTIVITIES
1. Of what Associations/Societies were/are you a member?

In School/Institute/Elsewhere Position Held Approximate Dates

2. Present hobbies / interest /

sports :

VI PERSONAL REFERENCE
Name Contact No. Profession Years Known to you
 Page 4 of 5 Form No.HRF01-002

VII GENERAL
1. Languages/Dialects written/spoken?
2. Are you suffering from any illness/disease?
3. Are you on any medication?
4. Physical disabilities or handicaps suffered:
5. Have you ever been convicted of a criminal Yes No
offence?
If Yes, give details
6. Have you been a member of any Employee Yes No
Union?
If Yes, state rank
7. Have you any relatives/friends you know in Yes No
our employment?
If Yes, give details

VIII How Did You Get To Know About This Vacancy?

Advertisement Employee Referral Others (Please Specify)

Campus Recruitment Agency Referral

Friends Vendor Referral

I declare that to the best of my knowledge, the particulars provided are true and I hereby give my consent to the company to
check my employment records with my previous employers. I am aware that any false or misleading statements made by me
will be cause for dismissal if employed.

I also authorise the Company to submit the said information to any person, firm, corporation, body, bureau, department, police
or government authority for the purpose of any investigation and verification of any information. I also indemnify the Company
from all liabilities, demands, claims, suits proceedings, costs and expenses of any nature in connection with the above matter.

Signature of Applicant Date

 Page 5 of 5 Form No.HRF01-002

INTERVIEWER COMMENTS:

1. New Headcount (additional personnel  Yes  No

2. Replacement of previous employee  Yes / Name:

 No
3. Salary Proposal IDR

4. Allowance Proposal IDR

5. Probation Period 3 (three) months  Yes  No

(probation IS NOT applicable for contract staff)

6. Contract Period  _____ months  _____ years

(contract period IS NOT applicable for probation staff)

7. Other comments

HR COMMENTS:

1. Salary Final IDR

2. Allowance Final IDR

3. Probation Period 3 (three) months  Yes  No

(probation IS NOT applicable for contract staff)

4. Contract Period  _____ months  _____ years

(contract period IS NOT applicable for probation staff)

5. Other comments

APPROVED BY: ____________________________ DATE : __________________

(Signature / Name)