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PERSONEL DATA FORM 3x4

Note : No. : ............................................

a. Fill in with BLOCK LETTERS
b. Fill in with cross mark (X) for the chosen answer

I. IDENTITY
Full Name : ________________________________________________ Nickname : _______________________
Place & Date of Birth : ___________________________________________________________________________________
Sex : Male Female

Address : ___________________________________________________________________________________
City : ________________________ Zip Code : _______________ Ph : _____________________________
Mobile phone number: ________________________________________________________________
Email: _____________________________________________________________________________
Office Address : ___________________________________________________________________________________
City : _________________________ Zip Code : ________________Ph : _____________________________
Nation : __________________________

II. EDUCATIONAL BACKGROUND

1. Formal Education
Name of School Major Place Time Period Comments
J.H.S
S.H.S
ACADEMY
S-1
S-2
S-3

2. Informal Education (Course / Training)

No Type of Course / Training) Place Time Period Comments
1
2
3
4
5
6
7
8

3. Foreign Language
Oral Written
No Language
Poor Fair Good Poor Fair Good
1
2
3
4
5

III. FAMILY STATUS

1. Marital Status : S S Single Engaged since ................ Married since ......................
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2. Immediate Families
Name M/F Place & date of birth Education
Wife / Husband
1st Child
2nd Child
3rd Child
4th Child
5th Child

3. Surbfamily members (Kinship)

Name M/F Place & date of birth Education
Father
Mother
1st Child
2nd Child
3rd Child
4th Child
5th Child
6th Child
7th Child
8th Child
9th Child
10th Chold

4. Transportation

Car Motorcycle Public Transportation

IV. OCCUPATIONAL BACKGROUND

1. Work Experience
Number of
No Company Period Position Last salary Reason for leaving
Subordinate
1
2
3
4
5

2. Explain your main job for each position above.

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

3. What changes have you tried to implement in your area of responsibility

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

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4. Describe the biggest problem you faced. How did you handle them ?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

5. Please explain an example of good decision you have made in the last six month ? What were the alternatives ?
Why you choose that decision ?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

6. What do you like most about your present job / position ? (Condition, tasks, or assignment) Why ?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

7. What do you like least about your present job / position ? (Condition, tasks, or assignment) Why ?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

8. Why did you choose this career (type of work) ?

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

9. Please give some example of experiences in your job that were satisfied & unsatisfied
Satisfied experience Unsatisfied experience
_____________________________________________ ________________________________________________
_____________________________________________ ________________________________________________
_____________________________________________ ________________________________________________

V. INTEREST & EXPECTATION

1. What are your career goals for the next five years ? What have already you done to accomplish them ?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

2. What are your reason for leaving your present position ?

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

3. Expected Salary Rp. __________________________________

4. Other facilities _____________________________________________________________________________________

5. Please rank 3 job fields that you interest most.

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

6. Do you have any objection being assigned out of Jakarta ? Yes No

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VI. SOCIAL ACTIVITIES

1. Sport : _____________________________________________________________________________________________

Hobbies : _____________________________________________________________________________________________

2. Organization :
No Organization Place Position Period
1
2
3

3. References
Name Address & Phone No. Relationship

VII. O T H E R S

1. What would be your strong point ?

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

2. What should be considered need improvement ?

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

3. Have you ever been hospitalized in the last 2 years ?

No Kind of disease Period Effect
1
2

I certify that the information contained in this personal data form is true and accurate.

_______________________________

Signature

( _____________________________ )

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