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PERSONEL DATA FORM

Note :
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 : ________________________ Ph : _____________________________
Office Address : ___________________________________________________________________________________
City : _________________________ Ph : _____________________________
Phone number : __________________________
Email : __________________________

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

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

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 og 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

4. Transportation

Car Motorcycle Public Transportation

IV. OCCUPATIONAL BACKGROUND

1. Work/ Internship Experience
No Company Period Position Salary
1
2
3
4
5

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

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

V. INTEREST & EXPECTATION

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

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.
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_______________________________

Signature

( _____________________________ )

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