JOB APPLICATION FORM

POSITION APPLIED FOR ___________________________

PLACEMENT _____________________________________
Photo
Please read through this application form carefully and
furnish all information required. Copies of certificates and
testimonials must be attached to this form. Originals must be
produced during the interview.

I. PERSONAL PARTICULARS

Full Name :________________________ Place of Birth :___________________

Address :________________________ Date of Birth :___________________
________________________ Citizenship :___________________
________________________ KTP No. :___________________
Tel No. : Office___________________ NPWP (Y / N), :___________________
No.
: Home___________________ :___________________
: Handphone______________ Religion :___________________
Driving : _______________________ Blood Type :____________________
Licence
Email address :_______________________ Gender : Male / Female
Marital Status : Single/Married/Divorced/Widowed/Separated

II. FAMILY PARTICULARS (Parents, Siblings, Spouse, Childern)

Name Relationship Age Occupation Name of Company/ School

III. LANGUAGE PROFICIENCY

LANGUAGES SPOKEN WRITTEN READ UNDERSTAND

Well Fair Poor Well Fair Poor Well Fair Poor Well Fair Poor

IV. EDUCATION (Attach all relevant certificates and detail results of final year)
From To Disipline of
DCR 1527, QR 2.1-1-3-d
Controlled document, unauthorized reproduction is prohibited.
 Name of School
Study or Major

SMA
DIPLOMA 1
DIPLOMA 2
DIPLOMA 3
UNIVERSITY
(BACHELOR DEGREE)
UNIVERSITY
(MASTER DEGREE)
Vocational
Professional Institute
Others
Part-Time courses
Studied now
Part-Time courses
which you intend to
study

V. EMPLOYMENT HISTORY (You are required to furnish proof (such as pay slip) of your last drawn salary)

Name & Address Basic Transport Other

Position Held From To Bonus
of Company Salary Allowance Allowance

Reason For Leaving:

Reason For Leaving:

Reason For Leaving:

Reason For Leaving:

Give a precise description
of your current job

Have you been dismissed/suspended from the service of any employer? Yes/No
If yes, please give details :

VI. HEALTH (If yes, please provide details)

Present state of health __________________________________________________________________
Illness or Accidents suffered since birth with approx. dates | Yes /No :_____________________________
Physical disabilities or handicap e.g. sight, hearing, speech, heart) | Yes /No :_______________________

DCR 1108, QR 2.1-1-3-c

Controlled document, unauthorized reproduction is prohibited.
 Undergoing any medical treatment now | Yes /No :_________________________________________
Vaccinated for Hepatitis B | Yes /No :___________________________________________________

VII. ACTIVITIES
1. Of what Associations / Societies are / were you a member?
In schools / Institutes / Companies/ Elsewhere Position Held Approx. Date
___________________________________________ ______________ ______________
___________________________________________ ______________ ______________

2. Present Interest / Hobbies : ___________________________________________________________

VIII. RELATIVES/FRIENDS YOU KNOW IN OUR EMPLOYMENT

Name Relationship Position Held in our Company From To

IX. REFERENCES (Character referees should not be family members/relatives)

Name Relationship Company Name /Tittle Contact Number

X. Emergency Contact (Character referees should be family members/relatives)

Name Relationship Address Contact Number

IX. GENERAL (If yes, please provide details)

1. Have you ever been convicted in a court of law? |Yes / No : _________________________________
2. Are you an undischarged bankrupt? |Yes / No : ___________________________________________
3. Have you been a member of any Employee Union ? | Yes / No : ______________________________
4. Termination notice for present job : 1 week / 2 weeks / 1month / Others ________________________
5. No. of days’ annual leave you have to offset your notice period _______________________________
6. Earliest date to start employment ______________________________________________________
7. Expected Salary ___________________________________________________________________

In consideration of my application for employment, I hereby consent to the Signature :

company’s collection and use of my personal data for review and evaluative
purposes for any subtitle job openings in the company. I declaire the answers
given by me are true and correct to the best my knowledge and ability. I
understand if after engagement, it is found that a false declaration has been Name :
made in this form, the Company reserves the right to terminate the Date :
employee’s service.

DCR 1108, QR 2.1-1-3-c

Controlled document, unauthorized reproduction is prohibited.