PT.

Amtek Engineering Batam

EMPLOYEE APPLICATION FORM Page 1 of 4
Pekerjaan yang dilamar :
Position Applied for
A. Data Pribadi :
A. Personal Information :
Nama / Name
Alamat Sekarang Telp.
Current Address

Alamat Tetap Telp.

Permanent Address

Tgl Lahir Tempat Lahir Jenis Kelamin

Date of Birth Place of Birth Sex
No. KTP No. Passport Warga Negara
ID No. Passport No. Citizenship
Status Keluarga Suku Bangsa Agama
Marital Status Race Religion
Suami / Istri Anak
Spouse's Particulars Children Particulars
Nama / Name No. Of Children
Pekerjaan Kelamin Nama Tgl. Lahir
Occupation Sex Name Birth Day
Alamat
Address

Keluarga
Family Particulars
Hubungan Nama Umur Pekerjaan
Relationship Name Age Occupation
Ayah
Father
Ibu
Mother
Kakak / Adik Nama Umur Pekerjaan
Brother / Sister Name Age Occupation

Dalam Hal Darurat

In Case of Emergency, to notify
Hubungan Nama
Relationship Name Telephone No. Alamat / Address

Bahasa / Dialek
Language or Dialect
Berbicara
Spoken
Tulisan
Written

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B. PENDIDIKAN
B. EDUCATION
Sekolah / Universitas Alamat Pendidikan Dari Sampai
School / University Address Education Level From To

Pelatihan / Kursus
Training Courses (incl. Academic, Professional or Trade Training):
Nama Lembaga Alamat Perihal Dari Sampai
Name of Institution Address Subject From To

Daftar keahlian yang dimiliki : misalnya ; ahli mesin, las, Tool & membuat Die, dsb.
List
List any
any basic skills
skills that
that you
you possess,
possess,eg.
eg.Machining,
Machining,ToolTool& &DieDieMaking,
Making,etc.:
etc.:

C. RIWAYAT PEKERJAAN
C.C.EMPLOYMENT
EMPLOYMENT HISTORYHISTORY
Present or latest Employer / Perusahaan Lama atau Sekarang :
Waktu Nama / Alamat Jabatan Gaji Bulanan
Period Employer's Name Address Position Monthly Salary
Dari / From Start
Sampai / To End
Jenis Usaha No. Pegawai
Type of Business Badge No.
Uraian Tugas
Brief Description of Responsibilities :

Alasan Berhenti Bekerja

Reason of Leaving

Strukture Organisasi dimana Saudara berada :

Please sketch your organisation structure below to show your position :

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Daftar Jabatan ( mulai dari jabatan terakhir ) :

Please list all jobs ( commence with present position ) :
Perusahaan / Alamat
Employer (Business & Location) Jabatan Tanggal / Dates Alasan Berhenti
Position Dari Sampai Reason for Leaving
From To

Apakah Kami boleh menghubungi bekas atasan Saudara ? YA / TIDAK

May we contact your current or past employer/s for reference ? YES / NO
Kapan mulai dapat bekerja ? Gaji yang diminta :
How soon after being offered Salary :
employment can you start work Expected :
D. BEKAS ATASAN SAUDARA
D. REFERENCES
No. Nama / Alamat Pekerjaan Tahun Berhubungan
S/N Name / Address Occuption Telphone No. Period Know

E. LAIN-LAIN :
E. OTHERS
S/N Pertanyaan / Question Ya/Yes Tidak/No Catatan / Remarks
1. Apakah Saudara masih terikat kontrak ?
Are you under any contract agreement
with other companies
Bila Ya, jelaskan
If Yes, please specify
2. Penyakit yang pernah diderita
Please state physical limitation, major illness
operation ?
Bila YA, jelaskan
If Yes, please specify
3. Apakah pernah terlibat masalah kriminal
charge ?
Bila YA, jelaskan
If Yes, please specify
4. Apakah ada sesuatu hal yang ingin disampaikan ?
Is there anything else you would like to tell us that may help us is considering your application ?

Dengan ini dinyatakan bahwa segala informasi adalah benar.

I hereby certify that the information given above is true and correct in every respect.

Tanggal : Tanda tangan :

Date _________ Signature __________________

HR-F02 Rev.01 01-02-2005

For Interviewer's use only Page : 4 of 4

Judgment on Applicant

1. Conduct during interview :

Self Confident Obliging Balanced Restrained Cumbersome
2. Capacity to absorb strain/stress :
Excellent Above Average Average Normal Unstable Easy
3. Participation in the Interview
Concentrated Lively Normal Unconcentrated Passive Erratic
4. Skills :
Excellent Above Average Average Average Moderate Incomplete Insufficient
5. Qualification for Job :
Over Qualified Just Right 75% Fit Unsuitable
6. Color Blind Test :
Fit Unfit (Total color Partially Fit (Red/Green Blindness)
Blindness)

Summary Interview :

Result : Reject Offer

Call For Next Interview

Interview Date & Time _______________________ Interviewed by : ______________________

If appointed :
Position Offered
Basic Salary Allowance
Other Benefits
Commencement Date Probation Period

Approved by : _______________ Date : _____________________

HR-F02 Rev.01 01-02-2005