Form: GEO-HRD-FR-05

EMPLOYMENT APPLICATION FORM

Photo 4 x 6

Position applied :

Please fill in with your own handwriting (in block letters blank ink)
Name Mr.
Mrs.
Miss.
First Middle Last

Addres : Street Number City - Country Handphone/ Phone

Current Address :

Permanent Address :

Place and date of birth :

Place Month Date Year

Marital Status 1. Single 2. Married 3. Divorce 4. Separated

Nationality :
Religion :

Put an X in the correct response number

Do you : 3. Own a car ? Yes No 6. Reside in a house owned by the company ? Yes No
1. Own a house ? Yes No 4. Own a motor cycle ? Yes No 7. Use a car owned by the company ? Yes No
2. Own a plot of land ? Yes No 5. Rent a house ? Yes No

Education (list all school attended)

Inclusive Date
School Name of School Area of Specialization
Form Till
Primary
Junior High School
Senior High School
Academy/University
 Form: GEO-HRD-FR-05

Occupation
Name Age Highest Education
Position Company
Father :
Mother :
Brother / Sister (Including Yourself)
1
2
3
4
5
6
7
8
9
10
Spouse :
Children
1
2
3
4
5

Training/Course
Name of institution Subject City Duration Financed by

Fair Good Excellent

State What Language You : Read
Speak
Write

List of Achievements
 Form: GEO-HRD-FR-05

EMPLOYMENT HISTORY : Give your employment history as completely and accurately as possible, beginning from the present or last employment
A. Service Years
Year Month Name / address / phone of firm Position Monthly Net salary
From Start :
To End :
Type of business : Total employees :
Line Supervisor : Director :
Reason of resignation :

B. Service Years
Year Month Name / address / phone of firm Position Monthly Net salary
From Start :
To End :
Type of business : Total employees :
Line Supervisor : Director :
Reason of resignation :

C. Service Years
Year Month Name / address / phone of firm Position Monthly Net salary
From Start :
To End :
Type of business : Total employees :
Line Supervisor : Director :
Reason of resignation :

Describe duties and responsibilities in your currrent / last position Describe the organization structure which shows your position

What office machine can you operate ?

 Form: GEO-HRD-FR-05

Reference give three (3) respons (not relatives) former employers or former teachers
Name Address Occupation

Hobbies and Activities

School / social organization activities (give name of organization)

Put an 'X' in the correct response box Yes No Remarks

Have you previously applied to our company / group ? If so when & what position :
Are you also applying to other companies ?
If yes please mention what companies and position applied
Are you under any contract agreement with other companies ?
Do you have any objection if we contact your previous employer for reference checking?
Do you have any acquaintance(s) or relatives(s) employed by our company/group ?
Please mention name and your relationship !
What serious illness/surgeries/accidents have you ever had? When have you had it ?
Have you ever undergone any psychological test before? When and for what purpose?
Have you ever been involved in any administrative, civil or criminal case ?
If accepted, do you agree to be located anywhere in indonesia?
Please mention the preferred cities and region !
Describe any kind of jobs that are in line with your career plan !
Please state your current monthly income and facilities !
Describe any kind of jobs you don't like !
State salary and facilities desired !
If accepted, when can you start working ?
I Hereby certified that the information given above is true and under any circumstances any misrepresentation or mission of information is found.
I Understand that I shall fully be held responsible.
Jakarta, …………………

(………………………….)
Applicant