Application Form

POSITION APPLIED FOR : RMO-GP PREFFERED LOCATIONS : SILOAM MEDIKA CANGGU

Please Complete This Form Properly

Personal Data
Full Name (same with ID Card) : MUHAMMAD REZA
Nick Name : REZA
Place of Birth : MEDAN
State : NORTH SUMATERA
Country : INDONESIA Photo
Date of Birth : 0 6 0 9 8 9
Gender : X Male Female Blood Type
Status : X Single Married, date Divorce
Religion : MUSLIM
Ethnic : ACEHNESE
Citizenship : X Indonesia Others
Height / Weight : 1 7 0 Cm / 8 1 Kg
E-mail Address : Rezamuhammad.muhammad@gmail,com

Skype ID :
Hobby : surf, scuba dive and foot ball
ID Card Number : 1 1 7 1 0 7 0 6 9 8 9 0 0 0 1 Expired Date
Passport Number : B 6 5 4 1 9 6 6 Expired Date
License Number : A 8 9 0 9 0 6 6 2 4 4 7 1 2
B1
C

NPWP Name : 80.360.085.7-101.000 NPWP Number

NPWP Address : JL.Mujur No 97 LAMLAGANG BANDA RAYA BANDA ACEH -NAD

Address (Original and Residential)

Original Address : JL.Mujur No 97 LAMLAGANG BANDA RAYA BANDA ACEH -NAD (number & street)
(Same with ID Card) RT : X RW: X
Kelurahan : Zip Code
LAMLAGANG 2 3 2 3 8
Kecamatan : City
BANDA RAYA BANDA ACEH
Province Country
NAD INDONESIA
Phone Number :
Handphone Number 1 : 0 8 5 2 9 2 3 0 5 9 8 0
Handphone Number 2 : 0 8 2 1 7 9 5 6 8 0 9 3

Residential Address : JL. Pengubengan kauh no 100X kerobokan kelod Badung Bali Indonesia (number & street)
(Current Address)
RT : x RW: x
Kelurahan : Zip Code
pengubengan kauh 8 0 3 6 1
Kecamatan : City
kerobokan kelod BALI
Province Country
BALI INDONESIA
Phone Number : 0 8 5 6 9 2 3 0 5 9 8 0

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Family Members & Emergency Contact
Family Members
Date of Birth
Relation Name Place of Birth M/F Address Occupation
(dd/mm/yy)
Husband /
Wife
Children
1

3
4

6
7

Parents

Father MASRA RAHIM MEULABOH 13-Oct-59 M JL.Mujur No 97 LAML Lecturer of University

Mother NURHAYATIE RANIE LANGSA 20-Sep-60 F JL.Mujur No 97 LAML Dentist

Siblings (Including yourself)

1
2

Emergency Contacts (FAMILY MEMBER)

Full Name : MASRA RAHIM
Date of Birth : 1 3 1 0 5 9 Gender X Male Female
dd mm yy
Place of Birth : MEULABOH
Relation : Sibling X Parents Others
Address : JL.Mujur No 97 LAMLAGANG BANDA RAYA BANDA ACEH -NAD

RT : X RW: X
Kelurahan : Zip Code
LAMLAGANG 2 3 2 3 8
Kecamatan : City
BANDA RAYA BANDA ACEH
Province Country
NAD INDONESIA
Phone Number :
Handphone Number : 0 8 1 3 6 0 9 5 2 9 2 8

Company Name :
City : BANDA ACEH
Position :

Educational Background (CERTIFIED)

1. College Name : UNIVERSITY OF SYIAH KUALA ( USK) BANDA ACEH
Educational Degree : Associate X Bachelor Master Doctor Others BACHELOR OF MD
Major :
City : BANDA ACEH
Years of Completed : 1 0 0 6 0 7 until 1 0 1 0 1 6 GPA : 3 , 0
dd mm yy dd mm yy

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2. College Name :
Educational Degree : Associate Bachelor Master Doctor Other
Major :
City :
Years of Completed : until GPA :
dd mm yy dd mm yy

Registration / License

Type Registration / License Number Exp. Date

ADVANCE TRAUMA SPINAL AND CERVICAL
ADVANCE TRAUMA LIFE SUPPORT FATMAWATI JAKARTA
EMERGENCY AND RESPONE IN COVID 19 PANDEMIC SET

Courses / Training

Subject Institution Period

SILOAM RTD FONTANA KUTA BALI UROLOGY BPH 2019
URO ONCO JOGJA FORUM 2O20
PROSTATE CANCER HASAN SADIKIN BANDUNG 2020

Languages

Language Read Write Speak Listen

ENGLISH FLUENTLY FLUENTLY FLUENTLY FLUENTLY
BAHASA INDONESIA FLUENTLY FLUENTLY FLUENTLY FLUENTLY

Organizations
Organization Name Position Period
IDI BADUNG BALI ACTIVE MEMBERSHIP 2019- Until Now

Special Achievements (Local / National / International)

Subject Year

Working Experiences (Start from your latest experience)

1
Company Name : prime plus medical
Latest Position : RMO-GP
Period : 1 9 0 7 1 9 until 2 5 0 1 2 1
dd mm yy dd mm yy
Reason for Leaving : OVER CONTRACT AND PLAN TO JOIN TO UROLOGY RESIDENCY
Basic Salary : 20.000000 - 30.000.000 nett/gross
Benefit : Car BPJS Medical Insurance Communication Allowance

Meal Transport THR X Bonus

Placement Allowance Positional Allowance Others

Company Address : JL SUBAK SARI CANGGU
City : BADUNG BALI INDONESIA
Company Type : Public Company X Private Company
State Own Company Others
Industry Type : HEALTH FACILITY
Division : PRIMARY CARE- URGENT CARE AND EMERGENCY ASSIST
Superior Name : dr. Buana Tri tunggal putra
Superior Position : HEAD MANAGER

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2
Company Name : OMSA MEDIC JIMBARAN - MARINA LABUAN BAJO
Latest Position : RMO-GP
Period : 0 5 0 9 2 1 until 20 0 2 2 2
dd mm yy dd mm yy
Reason for Leaving : DIALY WORKER AGREMENT CONTRACT FOR FIVE MONTH
Basic Salary : 15,000,000 nett/gross
Company Address : JL . ULUWATU II NO 86 BADUNG BALI INDONESIA
City : BALI
Company Type : Public Company X Private Company
State Own Company Others
Industry Type : HEALTH FACILITY
Division : PRIMARY CARE- URGENT CARE AND EMERGENCY ASSIST
Superior Name : dr Romy
Superior Position : HEAD MANAGER

3
Company Name :
Latest Position :
Period : until
dd mm yy dd mm yy
Reason for Leaving :
Basic Salary : nett/gross
Company Address :
City :
Company Type : Public Company Private Company
State Own Company Others
Industry Type :
Division :
Superior Name :
Superior Position :

Job Descriptions (Latest Position)

01.

02.

03.

04.

05.

Organization Chart (Latest Position)

Professional References (Must be filled)

Name Company Name Position Contact Number Relation
dr Buana Prime Plus medical HEAD MANAGER 82196668515 COLLEAGUES
dr Angga Krisna Bali sehat rotary Club C HEAD MANAGER 8563998227 COLLEAGUES

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Medical History

Last Medical Check-Up : 0 1 0 2 2 2

dd mm yy
Medical Check-Up Type : Regular Check-Up Sickness
General Check up Others
Place : X Hospital SILOAM DENPASAR
Clinic
Others
Allergic : Yes
X No
Have you had any serious illness / surgeries / accidents ? X Yes SLIPPING RIB SYNDROME
No
Have you ever been hospitalized within the last 2 (two) years? Yes
X No
Smoking : X Yes No
Eyes Condition : Silinder Minus Plus X Others
Others
Strength Weakness
DISCIPLINE AND ON TIME OVERTHINKING
HARD WORKER PEOPLE PLEASER BEHAVIOR
PASSIONATE WITH EMERGENCY AND SURGERY
Expected Monthly Salary 10,000,000
Expected Benefits HEALTH INSURANCE

Expected Facilities

Availability 1 month notice Others ________________

dd mm yy
I'm willing to have psychological test & medical check-up X Yes No

Have you ever been involved in criminal case ? Yes X No

If you have, when is it? NEVER

What is the biggest failure in your life? FALLING IN LOVE WITH WRONG PERSON

What is the biggest success in your life? JOIN WITH PRIME PLUS MEDICAL AND WORK IN BALI, HANDLING INTERNATIONAL PATIENT WITH W

What usually causes stress to you? How do you manage it? SURF AND MEDITATION

Have you ever been through any recruitment process in Siloam Hospitals Group and its subsidiaries?
If you have, when is it? YES , IT WAS LAST YEAR IN SILOAM MATARAM

Do you have any family or friend who is working within Siloam Hospitals Group and its subsidiaries?
If you have, please provide us with the details! (Name, Occupation, Relation, and unit) NO I DON’T

Do you agree to be located anywhere in Indonesia ? Yes X No I PREEFER TO WORK IN BALI

If yes, please mention the preferred cities of region ?

Where did you get the information of job opportunities of this company? INSTAGRAM

Declaration
I hereby certify that the above statements are true and correct; and that this application form is completed to the best of my knowledge.
I understand that if employed, falsified statements or any kind or omissions of facts called for on this application shall be considered sufficient
basis for dismissal.

Signature
........MEDAN ,MAY 16th 2022................., .................................

MUHAMMAD REZA, MD
__________________________

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ERNATIONAL PATIENT WITH WESTERN STANDART

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Formulir Lamaran Kerja