APPLICATION FORM

No. FM-HNRD-02-01 Rev. 02 page 1 of 6

CONFIDENTIAL

1. This form should be answered written in block capital letters by the applicant.
2. If any information given is not true, the company has the right to cancel or terminate the work relationship or as
demanded in law procedure.
3. * Cross where not appropriate.

Job Applied :

A. PERSONAL DATA

Full Name : Male/Female *

Place/Birthdate :

Hobbies :

Religion : Ethnic Group :

Formal Education : Title :

KTP No : Issued in :

Telp. No. : E – mail :

Address :

B. FAMILY
1. Marital Status Single Married
Engaged Divorced

2. Members of family ( Husband/Wife and Children )

If they have passed away, please mention their last education & job.
How many children do you have? _______

Family Name M/F Birthdate Education Job

Spouse

Child 1

Child 2

Child 3

3. Do you have other dependents besides your wife or children ?

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CONFIDENTIAL
4. House Status
Private owned Parent Owned Relative owned
Rent Contract Other .....................

5. Parents’ family (including applicant)

If they have passed away, please mention their last education & job.
Applicant is the ________ child of __________ children.

Family Name M/F Birthdate Education Job

Father M

Mother F

Child 1

Child 2

Child 3

C. EDUCATION
1. Formal Education (begin from Senior High School)

no Institution Name Major Place From To

a.

b.

c.

2. Have you ever failed in school ?______________How many times ?______________

Why?____________________________________________________________________________

3. Did you ever get any achievements in any field? If yes, please describe briefly.

4. Do you posses any computer skills? If yes, please describe briefly.

5. Courses Attended
no Topic Of Course Organizer Period

a.

b.

c.
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CONFIDENTIAL
6. Foreign Language

a. Speak * Read * Write *

b. Speak * Read * Write *

D. WORKING EXPERIENCE (please mention the last 3 company)

1. Name of Company

Line of Business

Period of work (month-year) up to

The last position

The job description

Reason for leaving

2. Name of Company

Line of Business

Period of work (month-year) up to

The last position

The job description

Reason for leaving

3. Name of Company

Line of Business

Period of work (month- up to

year)

The last position

The job description

Reason for leaving

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No. FM-HNRD-02-01 Rev. 02 page 4 of 6

CONFIDENTIAL
E. EMERGENCY CONTACT
Name the contact person that company can reach should emergencies occur

no Name Relationship Telp No.

1.

2.

F. REFERENCES
Name your references (not less than two, not in this company, nor your friend or family)

no Name Position Relationship Telp No.

1.

2.

G. INTEREST AND PERSONAL CONCEPT

1. Please indicate by number, your choice of job type, according to your preference.
Kinds of job No. Kinds of job No.
Accounting Human Resource/Personnel
Engineering Purchasing/Logistic
Finance Research
General Affair Service/Maintenance
Marketing/Sales Other____________________

2. Why do you choose the first 2 numbers in the above?

3. The working environment you prefer :

Office Factory Laboratory Field
Why?

4. Why do you want to join this Company?

5. What do you know about this Company

6. Do you have any objection to work overtime, to be stationed anywhere deemed necessary by the

Company?

7. When will you be able to start working?

8. What kind of Fringe benefits (facilities) do you desired?

9. Name the person (s) or your relative (s) in our company

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No. FM-HNRD-02-01 Rev. 02 page 5 of 6

CONFIDENTIAL
10. Did you ever do the Psychological test (IQ, Aptitude, Personality test) ? If yes, please mention where, when and
for what purpose?.

11. Did you ever involve in criminal cases? If yes, please describe the case, sanction, where and when!

12. Social Activities

no Name of Organization Period Position

a.

b.

c.

Hereby, I certify that the above statements are true and correct.
Jakarta, ............................................

( ____________________________ )
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No. FM-HNRD-02-01 Rev. 02 page 6 of 6

CONFIDENTIAL
SALARY AND FRINGE BENEFIT
A. Describe your last nett salary and other fringe benefit that you get from your current and previous working
experience. Adjust the sequence with the sequence in part D (working experience).
1. Company 1

Basic Salary

Meal

Transportation

THR & Bonus times a year

Other benefit

2. Company 2

Basic Salary

Meal

Transportation

THR & Bonus times a year

Other benefit

3. Company 3

Basic Salary

Meal

Transportation

THR & Bonus times a year

Other benefit

B. What is your expected salary?