APPLICATION OF EMPLOYMENT

(to be completed in BLOCK LETTERS and BLACK INK only)

Private & Confidential

Personal Particulars
First Name:
Last Name:
Name in past:
Religion: Moslem Buddhist Hindu Christian Catholic
Marital Status: Single Married Divorced Number of Children:
Gender Male Female Date of Marriage :
KTP# (Indonesia ID):
Jamsostek ID: Birth Date :
NPWP# (Indonesia Tax): Birth City :
Citizenship: Birth Country :

Residential Street
Address:
City Postal Code

Contact #: Home 62 21
Country Code Area Code Phone Number 1 Phone Number
Mobile 62
Country Code Mobile Number 1 Mobile Number 2
Personal Email:

Information of Spouse (if applicable)

First Name:
Last Name:
Birth Country: Birth City: Birth Date:
Employer:
Occupation:
Contact #: Mobile Country Code 6 2 Telephone

Information of Children (if applicable)

First Name:
Last Name: Gender:
Birth Country: Birth City: Birth Date:

First Name:
Last Name: Gender:
Birth Country: Birth City: Birth Date:

First Name:
Last Name: Gender:
Birth Country: Birth City: Birth Date:

First Name:
Last Name: Gender:
Birth Country: Birth City: Birth Date:

Information of Parent & Siblings (if applicable)

First Name Last Name M/F Date of Birth Education
Father
Mother
First Child
Second Child
Third Child
Forth Child
Fifth Child
Sixth Child
Parent's Home Country Code 6 2 Area Code Telephone
Contact #: Mobile Country Code 6 2 Telephone
Private & Confidential
Information of Emergency Contact
First Name
Last Name:
Relationship
Contact #: Home Country Code 6 2 Area Code Telephone
Mobile Country Code 6 2 Telephone

First Name
Last Name:
Relationship
Contact #: Home Country Code 6 2 Area Code Telephone
Mobile Country Code 6 2 Telephone

Employment Background (Give all periods of employment up to present position, including PETRINDO employment. Use addi
Company Name: Start Date:
Business Type: End Date:
Company Location:
Position:
Job Description &
Responsibility:

Report to:
Reason for leaving:
Last Gross Salary:
Contact: Name
Title
Phone Country Code Area Code Telephone

Company Name: Start Date:

Business Type: End Date:
Company Location:
Position:
Job Description &
Responsibility:

Report to:
Reason for leaving:
Last Gross Salary:
Contact: Name
Title
Phone Country Code Area Code Telephone

Company Name: Start Date:

Business Type: End Date:
Company Location:
Position:
Job Description &
Responsibility:

Report to:
Reason for leaving:
Last Gross Salary:
Contact: Name
Title
Phone Country Code Area Code Telephone
Private & Confidential

Company Name: Start Date:

Business Type: End Date:
Company Location:
Position:
Job Description &
Responsibility:

Report to:
Reason for leaving:
Last Gross Salary:
Contact: Name
Title
Phone Country Code Area Code Telephone

Company Name: Start Date:

Business Type: End Date:
Company Location:
Position:
Job Description &
Responsibility:

Report to:
Reason for leaving:
Last Gross Salary:
Contact: Name
Title
Phone Country Code Area Code Telephone

Education Details (Starting from the highest qualification)

College Name:
Country:
Degree Earned: Year Earned:
Major:

College Name:
Country:
Degree Earned: Year Earned:
Major:

College Name:
Country:
Degree Earned: Year Earned:
Major:

Language Ability
Language Native Read Write Speak
Y/N High / Moderate / Low High / Moderate / Low High / Moderate
Y/N High / Moderate / Low High / Moderate / Low High / Moderate
Y/N High / Moderate / Low High / Moderate / Low High / Moderate
Y/N High / Moderate / Low High / Moderate / Low High / Moderate
Y/N High / Moderate / Low High / Moderate / Low High / Moderate
Private & Confidential
Computer & Software Ability
Computer/Software Type Skill
High / Moderate / Low
High / Moderate / Low
High / Moderate / Low
High / Moderate / Low
High / Moderate / Low

Professional Training
Training Venue Period

Reference
How were you referred to us? E-recruit / agency / write in / advertisement / employee referral / Others (Please
Have you previously been employed in any PETRINDO organization? Yes
If yes, please provide: Position:
Country: Start Date:
Location: End Date:
Reason for Leaving:

Have you previously applied for employment with any PETRINDO organization? Yes
If yes, please provide: Position applied: When:
Result of your applicat

Relative Working in PETRINDO (Permanent or Contract or Temporary staff) (if applicable)

(Relatives are defined as spouse, child, parent, brother/sister, uncle/aunt, nephew/niece, parents in-law, brother/sister in-la

Do you have any relative working in PETRINDO`group companies? Yes

Name:
Relationship:
Department:
Contact #: Phone Country Code Area Code Telephone

Name:
Relationship:
Department:
Contact #: Phone Country Code Area Code Telephone
Name:
Relationship:
Department:
Contact #: Phone Country Code Area Code Telephone

Do you have any outside business activities besides employment with PETRINDO group companies? Yes
Company Name:

Address:
Fee Payable:
Private & Confidential
Have you ever been involved in any criminal activities (weapons, money laundering, drugs Yes
related, physical assults etc)?
If yes, please explain:

Have you ever been involved in a criminal lawsuit or in civil court? Yes
If yes, please explain:

Have you ever been discharged / requested to resign from employment? Yes
If yes, please explain:

Have you ever had issues related to banking / trading licenses before? Yes
If yes, please explain:

Have you ever been addicted in drugs, alcohol or any other similar condition? Yes
If yes, please explain:

Have you ever had a bad credit history with any banks, loan companies, and/or credit card companies Yes
If yes, please explain:

Are you holding an officer, director or executive power in an organization or firm? Yes
If yes, please explain:

When will you be able to join us?

Please state your expected salary:

Consent Form
CREDIT CHECK:
I authorize PETRINDO to conduct a background review of my credit information, such as credit history of past and pendin
accounts and payment history as a condition of my being offered employment. I authorize the banking/lending institutio
information about my credit status. I hereby hold PETRINDO and its officers, employees and authorized representatives,
liability arising from or as a result of the execution of this authority.

BACKGROUND CHECK:
I understand that I am being considered for a position (or have been offered employment) with PETRINDO and its subsid
allow me access to highly sensitive information concerning the Corporation's technology and systems. As a condition of m
(or continuing my employment), I hereby consent to the Corporation's conducting a background information review of m
will include, but not limited to, a copy of my most recent performance evaluation, most recent security clearances (if app
previous / current employer (s) concerning my professional qualifications, work performance, and ethical standards.

I authorize the contacts listed on Employment Background section to provide the Corporation with any requested inform
I hereby waive any claims against the Corporation and its current / former officer, directors, employees for performing th
I understand the Corporation has a sole discretion to determine the eligibility for employment.

PERSONAL DATA AUTHORIZATION

I fully understand and accept that in the evaluation of my application and, if hired, for the duration of my employment, i
circumstances, background, credit experience, service record and other employment data (collectively, "Personal Data")
the branches, subsidiaries and affiliates of PETRINDO. I further understand and accept that PETRINDO maintains comput
Indonesia and that PETRINDO and its affiliated companies may collect, store, process, disseminates or use my Personal D
transferred or accessed from computer systems owned or operated by or on behalf of PETRINDO or its affiliated compan
By signing this form, I expressly manifest my consent to PETRINDO' collection, storage, processing, dissemination or use
PETRINDO' or its affiliated companies' administration of its human resources policies and programs.

I hereby apply for employment in PETRINDO. I certify that all statements made in this application, to the best of my know
any fact or circumstances, which would, if disclosed, affect my application unfavorably. I understand that any false inform
sufficient cause for termination at any time if employed. I also authorize PETRINDO to check/verify any information cont
I accept that failure of consent to the credit check, background check and drug test will render me ineligible for employm

Applicant's Name: Applicant's Signature: Date: (dd/mmm/yy)

 F/HR/08/R0
)

Page 1 of 5

Latest
photograph

3X4

Phone Number 2

Mobile Number 2

Male Female

Male Female

Male Female
Male Female

Occupation
 Page 2 of 5

NDO employment. Use additional sheet if necessary)

 Page 3 of 5

GPA:

GPA:
 GPA:

Speak
High / Moderate / Low
High / Moderate / Low
High / Moderate / Low
High / Moderate / Low
High / Moderate / Low
 Page 4 of 5

Period

eferral / Others (Please specify)

No

No

n-law, brother/sister in-law, son/daughter in-law)

No
 No

Fee Payable:
 Page 5 of 5

No

No

No

No

No

No

No

story of past and pending loans, credit card accounts and other asset
anking/lending institutions and card companies to provide
horized representatives, free and harmless against any loss, damage or

PETRINDO and its subsidiaries and affiliates ("the Corporation") that will
tems. As a condition of my being considered for employment
information review of my employment experience. This review
ecurity clearances (if applicable) and a discussion with my
d ethical standards.

th any requested information about my previous employment.

loyees for performing the background information review.

on of my employment, information regarding my personal

tively, "Personal Data") may be shared between and among
INDO maintains computer systems in data centers and at other locations in
tes or use my Personal Data in manner that causes it to be
or its affiliated companies throughout its computer network.
g, dissemination or use of my Personal Data for all purposes relating to

n, to the best of my knowledge, are true. I have not knowingly withheld

and that any false information on this application will be
fy any information contained in this application.
e ineligible for employment.