F OR M U L IR L A M A R A N K E F o to

Phot ogr aph

RJ A 4x6
E M P L O Y M E N T AP P LI C ATI O N F O R M
(H a ra p m e n g g u n a ka n h u ru f ce t a k - Pl e a se u se bl o ck l e tt e rs)

P os is i y a ng dila m a r ( Positi on Appli ed) :

Lok a s i ( Loc ati on) :

D A T A P R I B A D I (P E R S O N A L D A T A )

N a m a L e n g ka p ( Full Na me )
T e m p a t & T a n g g al L a hir
U sia (Ag e) : _ Tah un (Y ea r s)
(Pla ce & Dat e o f Bir th )
No. KTP/SIM Je nis Kel amin : La ki-la ki/P e re mpu an
(I D C ar d Nu mb er ) Se x Male/ F em ale
Al a m a t S u rat
(C or re spo nde n ce Add re ss)

No. H and ph one 1 :

N o m o r T e le p o n (P ho ne Nu mb er )
Mobi le N um be r 1
Al a m a t R u m a h (Pe r man ent Ad dr e ss)
se suai K TP – a s sta ted in I D

No. H and ph one 2 : Mobi

N o m o r T e le p o n (P ho ne Nu mb er )
le N um be r 2
St a t u s P e ni ka h a n (M arit al Sta tu s) L aj a n g/ M e ni ka h / B e rce rai (Si ngl e/ Ma r ried/ Wido w/ Di vo r ce d)
Ju m l a h A n a k ( Nu mb er of C hil dre n) Ora n g (pe r so n)
K e b a n g sa a n ( Nati o nal it y) A g a m a ( Rel ig io n) :
Al a m a t E m ail ( Em ail Add re ss)

PEN DIDIKAN F O R MAL (F OR MA L ED UC ATI ON)

Ti n g kat N am a S eko l ah Ju ru san T ah u n M asu k T ah u n S el esai IP K
(Le vel) (N am e o f S ch ool (M aj or ) (Ye ar Sta rt ed ) (Ye ar C om pl ete ( GPA
) d) )
D a sa r
(Ele men ta r y)
M e n e n g a h P e rt a m a
( Juni or Hig h)
Menengah Atas
(Se ni or Hi gh )
A ka d e m i
(A ca de m y)
U ni ve rsi t a s
(U niver sit y)

PT IN D OL AK T O – Hu man R e sou r ce s Di vi sion Page 1 of 4

P E N D I D I K A N I N F O R MA L (I NF O R MA L E D UC AT I ON : C O UR SE S/ T RAI NI N GS /SE MI NA RS )
Nam a Program P en y el en g g ar a Tahu n S ert i f i k at
(N am e o f P rog ra m s) (H eld by ) (Ye ar ) (C er tified )

K E A H L I A N K H U S U S ( mi sal. : K om put er , M en geti k, dl l. – ting ka t p eng ua saan : K ur ang , Cu ku p, B ai k, S ang at B ai k)

SP E CIAL SKI LLS ( eg. : Co mpu te r, T ypin g, et c – skill le vel : Po or , Fair , Go od, Ve r y G ood )
K e a h l i an (S T i n g k at P en g u a s a a n ( Le vel)
kill)

K E M A M P U A N B A H A S A ( ting ka t p eng ua saan : K ur ang , Cu ku p, B ai k, S ang at B ai k)

LAN G U A GE P R O FI CI EN CY ( skill le vel : Poo r, F ai r, G oo d, V e ry Go od )

B a h a s a (La ng uag e) B e rb i c ar a (V er bal ) M e n u l i s ( Wri tte n)

P E N G A L A MA N K E R J A ( ha ra p di mulai d en gan pe kerj aan te ra khir )

WO R KI N G EX PE RIE N CE (ple a se st ar t with yo ur cu rrent/l ate st e mplo
ymen t)

1. N a m a P e ru sa h a a n
(C om pa ny N am e) :
L a m a B e ke rj a ( Wor kin g P erio d)
:
Al a m a t/ L o ka si (Ad dr e ss/L o catio n)
: T el e p o n (P hon e) :
P o si si t e ra khi r (L as t P o sition )
:
Ga ji t e ra khi r (L a st S al ar Rp.
:
y) B e n efi t ya n g dit e ri m a
(Be nefit A ccep ted ) :
T a n g g u n g ja w a b u t a m a
(M ain Re sp on sibi li tie s) :

Al a sa n kel u a r (R ea son f or lea vin g)

:

S t r u kt u r O rg an i s a si ( g a m b a r k an p o si si an d a s e k ar a n g )
O rg ani zatio nal cha rt (ple a se in dicate you r cur re nt p o sition )

PT IN D OL AK T O – Hu man R e sou r ce s Di vi sion Page 2 of 4

2. N a m a P e ru sa h a a n
(C om pa ny N am e)
:
L a m a B e ke rj a ( Wor kin g P erio d)
:
Al a m a t/ L o ka si (Ad dr e ss/L o catio
n) : T el e p o n (P hon e) :
P o si si t e ra khi r (L as t P o sition ) :
Ga ji t e ra khi r (L a st S al ar : Rp.
y) T a n g g u n g ja w a b u t a m :
a (M ain Re sp on sibi li tie s)

Al a sa n kel u a r (R ea son f or lea vin g) :

N a m a P e ru sa h a a n
3. (C om pa ny N am e) :
L a m a B e ke rj a ( Wor kin g P erio d) :
Al a m a t/ L o ka si (Ad dr e ss/L o catio
: T el e p o n (P hon e) :
n)
P o si si t e ra khi r (L as t P o sition ) :
: Rp.
Ga ji t e ra khi r (L a st S al ar
y) T a n g g u n g ja w a b u t a m
:
a (M ain Re sp on sibi li tie s)

Al a sa n kel ua r ( Rea son f or lea vin g) :

K E G I A T A N O R G A N I S A S I (* m i sal : ke p e m u d a a n, p oliti k, so si al , p ro f e si )
O R GA NI ZA TI O NA L A C TIV IT IES (*e g. : you th, pol iti c, so ci al, p rof e ssion al)

N a m a O r g an i s a si P o si si J en i s O rg an i s a si * P eri o d e
(N am e o f O rga nizati o n) (Po sitio n) (Type of O rg ani za tion* ) (Pe riod )

H O B I D A N MI N A T (H O BB IE S A N D I N TE RES TS )
1.
2.

D A T A K E L U A R G A (FAM I LY BA CK G R O UN D )
N am a T an g g al L ah i r P en d id i kan P eke rj aan
H ub u n g an ( Rel on )
ati (N am e) (D ate of Bi rt h) (Ed u catio n) ( O ccup ati o
n)
Sua mi /I st ri (S po u se )
1.
Ana k ( Chi ld ren )
2.
3.

Ay ah ( Fat he r)

Ibu (M oth er )
1.
Saud a ra
Kand un g 2.
(Sibl ing s)
3.
4.
5.

PT IN D OL AK T O – Hu man R e sou r ce s Di vi sion Page 3 of 4

KERA BA T DEKA T YAN G DA PAT DIHU BU N GI PAD A SAAT D AR UR AT
Nam a A l a m at / N o m o r T el ep o n H u b u n g an
(N am e) (Ad dr e ss/ P ho ne ) (R el ati o n)

R E F E R E N S I (h a ra p se b ut ka n n a m a re ka n ke rj a )
RE FE RE N CES (ple a se gi ve na me of yo ur col lea gue s)

Nam a A l a m at / N o m o r T el ep o n P e k erj a an H u b u n g an
(N am e) (Ad dr e ss/ P ho ne ) ( O ccup ati o n) (R el ati o n)

K E R A B A T A T A U T E MA N Y A N G B E K E R JA D I I N D O F O O D
REL A TIVE S O R FR IE ND S WO RK IN G I N I ND O F O O D

N a m a ( Na me ) P o si si (P o sition ) U n i t / D e p t . / Di v. H u b u n g an ( Rel ati o n )

G A JI & B E N E F I T Y A N G D I H A R A P K A N (SA LA RY & BE NE FI TS EX P EC TE D )

1. Ga ji p e r b ul a n (E xp e cte d S al ar y pe r mo nth ) : Rp.
2. B e n efi t/ F a sili t a s (E xpe ct ed be nefit s) :

L A I N N Y A ( O T HE RS )

P ert a n y a an T u l i s k an Y a/ T i d a k & C at at a
( Qu e stion s) n
(Plea se st ate Ye s/ No & Not e)
A p a ka h A nd a p e rn a h m el a m a r di gr u p / p e ru sa h a a n i ni se b el u m n ya ? Ji
ka ya , ka p a n ? d a n u nt u k p o si si ap a ?
Ha ve you ap pl ied fo r a n y e mplo yme nt i n thi s g ro up/ com pan y be fo re? If ye
s, wh en? An d fo r wh at po sition ?
A p a ka h A nd a p e rn a h m e n g al a m i sa kit p a ra h/ op e ra si/ ke cel a ka a n ?
Ha ve you e ve r had an y se riou s disea ses / o pe ratio n s/ a cciden t s?
A p a ka h A nd a p e rn a h b e ru ru sa n d en g a n pi h a k ke p oli si a n at a u p e
n g a dil a n t e rka it d e n ga n ka su s kri mi n al at a u h u ku m l ai n n ya ?
Ha ve you e ve r offi cial ly en ga ged wit h P oli ce D epa rt me nt i n rel ati on
to crimin al i ssue, cou rt of j u sti ce o r civil ca se s?
A p a ka h A nd a b e rse di a m el a ku ka n p e rj al a n a n di n a s ?
Willi ng to do bu ssin e s t rip?
A p a ka h A nd a b e rse di a u n t u k dit e m p a t ka n di ko t a l ai n ?
Willi ng to be st ati o ned in o the r cit y?
Ji ka A n d a dit e ri m a , ka p a n A n d a d a p at m ul ai b e ke rj a ?
If you a re a ccept ed, w he n yo u ca n sta rt wo r kin g?

S a ya m e n ya t a ka n b a h w a i nf o rm a si ya n g di b e ri ka n di at a s a d al a h j uj u r da n b e n a r. S a ya m e m a h a m i b a h w a p e m
a h a m a n ya n g b e rb e d a d a n p e n yi m p a n g a n i n f o rm a si a ka n b e rd a m p a k p a d a p ro se s p e n e ri m a a n d a n p e m ut u sa n h u b u n g
a n ke rj a ji ka sa ya t ela h di t e ri m a b e ke rj a ol e h p e ru sa h a a n (I de cla re all the inf or mati on gi ve n ab o ve is t ru e an d
co r re ct. I un de r sta nd tha t an y mi srep re se nta tion o r o mi ssion of fa cts will be suf ficie nt cau se f or can cel latio n o f co n side rati on
fo r empl o yme nt or di smi ssal f ro m t he C om pan y’ s ser vi ce if I h a ve be en em plo ye d) .

T a n d a t a n g a n & n a m a P el a m a r
T a n g g al :
(Ap pl ic ant’ s sig nat ur e & na me )
(D ate )

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