APPLICATION FORM

CONFIDENTIAL
USE CAPITAL LETTERS
Position applied for :

I.

Photo 4x6

PERSONAL DATA
A. Personal Details
Full Name:
Place of Birth:

Sex:
Religion:

Date of Birth:

Home Address & phone

Identity Card No.

Marital Status:
- Married
- Single
- Others

Hand phone :
E-mail :

Office phone:

B. Family Details
(Spouse and children)
Name

M/F

Age

Education

Job

Company

C. Family Details
(Father, mother, brothers/sisters including you)
Name
M/F

Age

Education

Job

Company

Spouse
Child 1
Child 2
Child 3

Father
Mother
Bro./Sis. 1
Bro./Sis. 2
Bro./Sis. 3
D. Health History
1. Have you had a rather severe illness/accident?
If yes, please describe

Month/Year

2. Does it have a side effect presently ?

If yes, please describe

II. EDUCATION AND SKILLS

1

A. Formal Education
Education
High School

Schools Name

Major

From / To

GPA

Academy
University

B. Non Formal Education : Course/Training/Seminar

Subject

Provider

Year/Period

Paid by

1.
2.
3.
C. 1. Scientific publication including thesis

2. Extra curricular / Social / Teaching Activities

Name of Activities / Organization

Position

Year/Period

1.
2.
3.
D. Languages (fluent/slight)
Fluent

Listening
Fair
Slight

Fluent

Speaking
Fair Slight

Fluent

Writing
Fair

Slight

1. English
2.
3.
E. Hobbies/sports

F.

Scholarship/awards/prizes received :

III. WORK EXPERIENCE

(Four latest experiences, others please attach on separate page)
Month

Year

Name/Address/Phone of Company

Position

Fr.:

First :

To

Last :

Type of Business :

Total Employees:

Name of Supervisor :

Name of Director :

Major Tasks & Responsibilities

Major achievements

No. of employees supervised:

Directly :

Indirectly:

Major reason for change :

Minor reason for change:

Month

Year

Name/Address/Phone of Company

Position

Fr.:

First :

To

Last :

Type of Business :

Total Employees:

Name of Supervisor :

Name of Director :

Major Tasks & Responsibilities

Major achievements
No. of employees supervised: Directly :

Indirectly:

Major reason for change :

Minor reason for change:

Month

Year

Name/Address/Phone of Company

Position

Fr.:

First :

To

Last :

Type of Business :

Total Employees:
3

Name of Supervisor :

Name of Director :

Major Tasks & Responsibilities

Major achievements

No. of employees supervised: Directly :

Indirectly:

Major reason for change :

Minor reason for change:

Month

Year

Name/Address/Phone of Company

Position

Fr.:

First :

To

Last :

Type of Business :

Total Employees:

Name of Supervisor :

Name of Director :

Major Tasks & Responsibilities

Major achievements

No. of employees supervised: Directly :

Indirectly:

Major reason for change :

Minor reason for change:
IV. SALARY & BENEFIT HISTORY
(Starting From Current / Latest Company)
1. Company Name :

2. Company Name :

Basic Net Salary :

Basic Net Salary :

Allowances (Transport, Meal, etc) :

Allowances (Transport, Meal, etc) :

Bonus/Commision :

Bonus/Commision :
4

Benefit (Medical, etc) :

Benefit (Medical, etc) :

3. Company Name :

4. Company Name :

Basic Net Salary :

Basic Net Salary :

Allowances (Transport, Meal, etc) :

Allowances (Transport, Meal, etc) :

Bonus/Commision :

Bonus/Commision :

Benefit (Medical, etc) :

Benefit (Medical, etc) :

V. PROFESIONAL REFERENCES
1. Full Name :

2. Full Name :

Company :

Company :

Address :

Address :

Relationship :

Relationship :

Phone :

Phone :

VI. SALARY AND COMMENCEMENT OF EMPLOYMENT

1.
2.

Desired nett monthly salary?

Earliest date able to commence employment

I hereby declare that every statement given by me in this form is true, correct and given voluntarily. I authorize the
Management to submit the said information to any person or organization for the purpose of any investigation which the
Management may desire to make. I agree that if any false declaration is made by me, my agreement may be terminated
without notice.

Jakarta,

2016

For official use only:

Remarks by Director of Human Resources:

Signature:

Date:

Remarks by Department Head:

Signature:

Date:

Selected Candidate (For HR Department)

Position: ______________________________________ Headcount:
_____________________________
Start Date: ____________________________________ Level:
__________________________________
Contract / Permanent: _________________________ Report to:
_______________________________

Other Comments :