KP/HRD/REC/01/001

Serial number : ............

EMPLOYEE APPLICATION FORM

Date ________________

1. Position Applied for : a. _______________________ 3. 3.

Photo
b. ______________________
3x4
2. Expected Salary : _______________________

4. APPLICANT INFORMATION

Applicant Name : ID Card Issued by, Issued from : Valid thru :

dd/m/year dd/m/year

ID Card Number.

Date of Birth : Place, dd/m/year : Nationality Religion Age Gender : M/F

M F
Home Address Phone

Correspondence Address Phone Email

5. APPLICANT STATUS

Marital Status : Employed Others

Married Single Others Company/Institution Name Since : To :

dd/m/year dd/m/year

Spouse Name : Place, date of Birth Occupation

1. Children Name : Place, date of Birth Gender :

M F
2. Children Name : Place, date of Birth Gender :
M F
3. Children Name : Place, date of Birth Gender :
M F
KP/HRD/REC/01/001
6. FAMILY BACKGROUND

Children ……..of ……...

1. Name of father Occupation Address

2. Name of mother Occupation Address

Phone :

7. PHYSICIAN INFORMATION

Height : cm Weight : kg Blood Type :

Recently of illness/injury/ surgery/ Hospitalization < 1 year > 1 year other
Diagnosis

8. EDUCATION BACKGROUND

Grade Name of School-Location Year of Graduated Degree Received

High School
Vocational School
Diploma
University

9. OTHER QUALIFICATION

SPEAK READ WRITE

Foreign Languages
Very Good Good Fair Very Good Good Fair Very Good Good Fair

Music/Sport/Other Description : Very Good Good Fair

10. MEMBERSHIP

Period
Name of Organization Position
From To

11. HOBBIES ;_______________________________________________________________________

KP/HRD/REC/01/001
12. EMPLOYMENT RECORD

Previous employment
Company Name Address & Period of Position Recommendation Reason for Leaving
Phone Number Employment Letter

1. Yes No

2. Yes No

3. Yes No

4. Yes No

Current employment at : __________________________ Address : _______________________

Starting date : ____________________________ Current Position : ______________________ _

Current Salary : ___________________________ Responsibility : _________________________

Reason for applying at PT. Karsa Prabala ______________________________________________________

13. PERSONAL REFERENCES

Recommended by Position Company Relationship as

Yes No
Are you related to anyone now employed in PT. Karsa
Prabala ? Name :
Name and address of person to notify in case of emergency:

Name Adress Phone

14. I hereby authorize investigation of all statements contained in this form and I understand that any false statements
made herein will be sufficient cause for termination without notice, severance pay or any compensation
whatsoever.

___________ , ____________________
Place Date/month/year

Signature ___________________

Name ______________________