No:

APPLICATION FORM Date:

Applied Division : Employment Status :

Assurance Tax TAS Advisory CBS - Support Permanent Internship

Applied Position : When can you start?

Full Name

(based on ID card/KTP) (First Name) (Middle Name) (Last Name)

Current Address

City Postal Code Country

Contact Mobile phone Home

Email Address Office

Where do you live ? own house rented house boarding house with parents others

Permanent Address
(based on ID Card / KTP / Passport)

City Postal Code Country

Identification Card No. (KTP/Passport*)

*) applied for expatriate employee

Sex (M / F) Age years old

Date of Birth Place of Birth

Citizenship Religion

Civil Status : Single Married Widowed Separated

No. of Children No. of Dependents

EDUCATION RECORD :
Inclusive Date Major Course Honors/R
Education Name of School City Degree GPA Certificate No.
From To or Subject ank
Senior High School
(SMU)
Academy

University

Postgraduate / Advance Studies

Others Courses

Computer skills

English skills Low Medium Good Excellent pHOTO Ph

Other language

Low Medium Good Excellent

Photo
Where did you hear about EY Career Website EY Campus Hiring
our job vacancy?
Application ID Location

Job Advertisement Others

If so, please specify If so, please specify

Application Form - EY Recruitment - 04/16

PROFESIONAL MEMBERSHIP QUALIFICATION (CPA, CIA, CISA, Brevet etc.)

Title of Certificate Name Professional Association/Organization No of Certificate Issued by (City, Country) Dates/Year Certification

RECORD OF EMPLOYMENT

Present Employer Past Employer 1 Past Employer 2 Past Employer 3

Company Name

Address

Nature of Business

Your position/title

Period of Employment
(Start - End)
Starting monthly
Salary (gross)
Present salary/ salary
Upon leaving (gross)
Reason for
Leaving

Have you ever been dissmissed or suspended by your previous employers ? If so, state date

by which company and the case

FAMILY BACKGROUND:
Give names and addresses of your family background
Occupation and
Name Address / Telephone
Employer
Father
Mother

Siblings

Spouse

Child

REFERENCES:
Give names and addresses of person/ contact number, preferably those in business or profession, who have known you for at least three years.
(Do not give names of relatives)

Number of Years
Name Address / Telephone Email Occupation and Employer
of Acquaintance

Are you related to any partner or employee of this Firm ? if so, to whom?

Name referral in our employ

Were you involved in any administrative, civil or criminal case? if so, please specify

Have you taken our entrance test before? If so, when date/year

Minimum monthly salary acceptable (Gross) Rp.

Application Form - EY Recruitment - 04/16

Explain briefly below your reason (s) for applying with us and state why you believe you are qualified for the position:

I certify that the printed information on this form or any supplements, and supported documents to support this form is complete and accurate.

I hereby authorize EY entities to perform employment reference checks on my previous employment, verify academic checking, and conduct full background checks including
personal references. This is not limited to overseas inquiries if necessary and, I authorize to release my personal data outside of Indonesia in the course of processing.

I consent to release my personal data to a third parties for background check purpose. I also consent the recipients of such enquiries to provide the data requested.

I understand that my offer is that I may withhold my permission and that in such a case, no investigation will be done and my application for employment will not be processed
further.

____________________________________
Signature

____________________________________
Name

____________________________________
Date

Application Form - EY Recruitment - 04/16

 PERNYATAAN KESEHATAN
HEALTH STATEMENT
___________________________________________________________________________________________

Nama Lengkap: ..................................................................................................... .....................

Full Name

Jenis Kelamin: 1. Pria/Male

Sex 2. Wanita/Female

Tanggal Lahir: ..…………………………................... Umur/Age: ……… Tahun/Year

Date of Birth

Status: 1. Belum kawin/Single

Marital Status 2. Menikah/Married
3. Cerai/Divorced

Data kesehatan (Bila ya, mohon dijelaskan)

Medical data (If yes, please explain)

1. Tinggi badan: ………… cm Berat badan: ………… kg

Height Weight

2. Dalam dua bulan terakhir, apakah Anda pernah sakit atau kecelakaan?
In the last two months, have you ever been sick or had an accident?

3. Apakah Anda dalam keadaan sehat, dan tidak dalam keadaan cacat atau sakit jiwa?
Are you in good health, and not having a physical disability or mental disorder?

4. Apakah Anda dan/atau anggota keluarga dekat* Anda sudah pernah atau pernah dirawat
disebabkan karena salah satu penyakit atau masalah kesehatan yang tercantum di bawah
ini?
Have you and/or immediate members of your family* ever had or ever been treated for any of
the following diseases or health problems?

a. Kelainan pada sistem peredaran darah (tekanan darah tinggi, serangan jantung, dll.)?
Circulatory System Disorder (hypertension, heart attack, etc.)?

b. Kelainan pada sistem pernafasan (TBC, asma, pneumonia, dll.)?

Respiratory System Disorder (TBC, asthma, pneumonia, etc.)?

c. Kelainan pada sistem saluran kencing? (batu ginjal, penyakit kelamin, dll.)?
Urinary System Disorder (kidney stone, venereal disease, etc.)?

d. Kelainan pada sistem pencernaan (hati, kandung kemih, usus halus, dll.)?
Digestive System Disorder (liver, gallbladder, intestine, etc.)?

Health Statement – Recruitment 02/18

 e. Kelainan pada sistem syaraf (epilepsi, kelainan mental/gangguan cemas, dll.)?
Nervous System Disorder (epilepsy, mental illness/nervous disorder, etc.)?

f. Kencing manis, kanker, tumor, atau luka berat ?

Diabetes, cancer, tumour, or severe bodily injury?

g. Kelainan pada kulit, kurang gizi, infeksi kronis, atau saran untuk menjalankan test HIV?
Skin disorder, undernutrition, chronic infection, or advised to undergo an HIV test?

h. Penyakit-penyakit lain yang tidak disebutkan di atas?

Other diseases not mentioned above?

5. Apakah Anda pernah atau dianjurkan untuk menjalani operasi, diperiksa oleh dokter, atau
sudah pernah menjalankan pemeriksaan kesehatan (tes darah, pemeriksaan sinar X,
elektrokardiogram, dll.) selama dua tahun terakhir ini?
Have you had or been advised to have an operation, been treated by a doctor, or had a
medical check up (blood test, X-ray, ECG, etc.) in the last two years?

6. Khusus untuk wanita:

Apakah Anda sedang hamil sekarang? Bila ya, dalam keadaan hamil ..... bulan
For female:
Are you current y pregnant? If so, stage of pregnancy is ..... months

PERNYATAAN DAN PEMBERIAN KUASA:

STATEMENT AND AUTHORIZATION:

Dengan ini saya menyatakan bahwa pernyataan saya ini semua benar, dan saya mengerti dan setuju bahwa apabila
pernyataan saya ini tidak benar, maka Perusahaan berwenang untuk menindaklanjutinya ke pihak yang berwenang
termasuk namun tidak terbatas untuk melakukan proses pemutusan hubungan kerja sesuai ketentuan dan peraturan
perundang-undangan yang berlaku. Dengan Pernyataan ini, saya memberi kuasa kepada semua dokter di rumah
sakit, klinik, perusahaan asuransi, atau perusahaan/lembaga, atau yayasan, atau perorangan, untuk membuat dan
mengirim laporan/ pernyataan ke Perusahaan mengenai kesehatan saya. Fotocopy dari pemberian kuasa atas
pernyataan ini akan dianggap sah berdasarkan hukum sebagaimana dokumen aslinya.
I hereby declare all statements made herein to be true, and understand that if any statement herein is found to be
false that the Firm is entitled to process such false information to the relevant authorities including but not limited to
process termination of employment agreement in accordance with prevailing laws and regulations. With this
statement I also authorize any doctor in any hospital, clinic, Insurance Company, or company/institution, or
foundation, or any other person, to prepare and submit a report/statement to the Firm concerning my state of health.
Any copy of this statement of authorization is to be considered as legally binding as the original document.

Date/Year
……………………………………

(Nama, Tandatangan)
Name, Signature

*) Yang dimaksud dengan anggota keluarga dekat adalah orang tua, kakak/adik, pasangan, dan anak (Immediate members of
the family mean your parents, brothers/sisters, spouse and children).

Health Statement – Recruitment 02/18