Employment Application

Applied for : __________________________________

Please fill in this form with your personal data with your own handwriting
* Cross out whichever does not apply
** Check one of the following options select
Photo

I. Personal Information
Full name Nick Name:
Place, Date of Birth Age :
Nationality Male/Female **
Religion Blood Type :
ID Number
Driver’s License. A /B I / B II / C /D ** NO :
Civil Status** Single / Married / Divorced
NPWP No
No. BPJS
Ketenagakerjaan
No. BPJS Kesehatan
Phone and Handphone
Email Address
ID Address ...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
.................................................................Zip Code............................................

Current Address ............................................................................................................................

............................................................................................................................
............................................................................................................................
...................................................................Zip Code...........................................

Emergency Contact Name ........................................................ Relation ..........................................

(Other than yourself) No. Handphone .........................................Local Phone……...............................
Address .............................................................................................................
...........................................................................................................................

FAMILY DETAILS
Occupation
Relationship Name M/F Age Last Education
Position Company
Father
Mother
Siblings 1
Siblings 2
Siblings 3
Siblings 4
Siblings 5
Filled this section if already married
Spouse
Child 1

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 Employment Application

FAMILY DETAILS
Occupation
Relationship Name M/F Age Last Education
Position Company
Child 2
Child 3

II. FORMAL EDUCATION

Certified
Year
Education Level Institution Name Location Specialization (Yes/No)
From To
Primary School -
Junior High School -
Senior High School
Diploma I/II/III/IV* GPA:
Bachelor Degree GPA:
Master Degree GPA:
Doctor’s Degree GPA:

FOREIGN LANGUAGE PROFICIENCY (Filled with: Fair, Good, or Excellent)

Language Listening Reading Speaking Writing Additional Info

Year Certified
Institution Name Field Location
From To (Yes/No)

III. WORK EXPERIENCE (Filled this section with your employement history from the latest experience)
Mont
Years of service Year Company Details Position
h
From Name
To Business Field
Total Employees Address & Phone Direct Reports

Reason of Resignation Director

Salary and Allowance

Mont
Years of service Year Company Details Position
h
From Name

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 Employment Application

To Business Field

Total Employees Address & Phone Direct Reports

Reason of Resignation Director

Salary and Allowance

Mont
Years of service Year Company Details Position
h
From Name

To Business Field

Total Employees Address & Phone Direct Reports

Reason of Resignation Director

Salary and Allowance

Mont
Years of service Year Company Details Position
h
From Name

To Business Field

Total Employees Address & Phone Direct Reports

Reason of Resignation Director

Salary and Allowance

Mont
Years of service Year Company Details Position
h
From Name

To Business Field

Total Employees Address & Phone Direct Reports

Reason of Resignation Director

Salary and Allowance

Draw the organization structure of your position in your last office.

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 Employment Application

Describe duties and responsibilities in your latest position.

Mention three strength of yourself: Mention three weakness of yourself:

1. 1.
2. 2.
3. 3.

IV. HEALTH RECORD

Have you been/are suffering chronic pain or heavy accident or surgery? If yes, please explain when, what kind,
and the effect of it until now.
_________________________________________________________________________________________
Do you have:
Yes No
1 Asthma
2 Hepatitis
3 Tuberculosis (TBC)
4 Heart Disease
5 Diabetics
6 Epilepsy
7 Allergy
8 Other disease that have not been
mentioned

Yes No
Do you smoke? Approx. ______________________
Are you drink alchohol baverages ? Kind of drink__________________
Do you use drugs? in year _____________________

Do you have problems with your five senses?

Yes No
1 Eyes Plus/Minus*
2 Color-blind

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 Employment Application

3 Smell
4 Hearing
5 Taste

Have you ever undergo any psychological examination or test? No / Yes,

If so, when, where, and for what purpose? _____________________________________________________

No. Put an X in the Correct Response Box Yes No Additional Info

Have you previously apply to our company? If so, when
1.
and what position?
Are you also applying to other companies? If yes, please
2.
mention which companies and position applied.
Have you worked at our company before? If so, when and
3.
for what position?
Are you under any contract agreement with company you
4.
are working now?
Do you have any side job? Please specify the company
5.
name and the position you held.
Do you have any objections if we contact your previous
6.
employer for reference checking?
Do you have any acquaintance(s) or relative(s) employed
7. by our group/company? If so, please mention the name
and your relationship.
Have you ever been involved in any administrative, civil, or
8.
criminal case?
9. Are you willing to go on tour of duty outside Jakarta?
Are you willing to be placed anywhere in Indonesia?
10.
Please mention the preferred cities and regions.

No. Fill in with short and clear answer

Describe any kind of job that are inline with your career
1.
plan!
2. Describe any kind of job that you are less favored!
3. If accepted, when can you start working?
4. Expected salary

I hereby certified that the information given above is true and if under any circumstances there are any
misrepresentations or omission of information is found, I understand that I am fully responsible for the
consequences, and willing to be penalized according to company policies and regulations.

…………………….,…………..

___________________

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Applicant

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