DESIGNATION Beautician

COMPANY NAME Monspace Indonesia (Monspace Stylist Channel)

EMPLOYEE PERSONAL DATA FORM

A. PERSONAL INFORMATION

Full Name (as in I/C) Malem Cori Ana Purba

Other Name Corie NRIC No. 1271075310830003

Passport No. C1106943 Nationality Indonesia

Date of Birth 13/10/1986 Age 33

Gender □ Male □
x Female

Marital Status □ Single □

x Married □ Divorced □ Widowed

No. of Children _____above 18 yrs old

Do you have children? □x Yes □ No
3 _____below 18 yrs old

Telephone No. (Mobile) +6285370721586 (Home)

Email Address corie.purba@gmail.com

Home Address Jl. Pantai Barat Gg. Bahagia No.5, Cinta Damai, Kec. Medan Hervetia,
Medan, Sumatera Utara 20126

EPF No. SOCSO No.

Income Tax Ref.

Bank Account No. 7860120610 Bank Name BCA

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 E. FAMILY INFORMATION

Name Relationship Employer Occupation

Roky Saputra, AmdKom Suami Freelancer

Adrian Getsemani
Anak SMP
Diva Manuella Ginting Anak SD
Listra Rehulina Ginting Anak TK

Roky Saputra
Spouse’s Name: _____________________________________ 1271072008820002
NRIC No. ____________________________________
Employment Status : □ Yes □x No Occupation : ______________________________________________________

Jl. Pantai Barat Gg. Bahagia No.5, Cinta Damai, Kec. Medan Hervetia, Medan 20126
Company: ______________________________________________________________________________________
3
No. of Children: _________________ 14 years
Age of eldest child: _____________ 5 Years
Age of youngest child: _________________

Do you have any friends / relatives currently employed with the Company or any of its brands? □ Yes □x No
If yes, kindly provide their details:

Name Relationship Position held

Kindly provide the name and contact details of two (2) persons that the Company may notify in the event of any
emergency.

Name Relationship Contact No.

DECLARATION

I hereby declare that to the best of my knowledge and understanding, the information given in this application is true
and correct. Pursuant to the Personal Data Protection Act 2010, by affixing my signature herin, I hereby agree to
authorize the Company to collect relevant information related to me, including information which may be of personal,
confidential and/or sensitive in nature, and to use and/or process such information for the purpose of my application
and/or thereafter, my appointment with the Company.

Name : Malem Cori Ana Purba

NRIC No. :
1271075310830003
Date :
13 October 1986
Signature

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