ANNEX A

EMPLOYMENT APPLICATION FORM

*Kindly note that all information will be kept strictly confidential.

Position Applying for: Nurse

PERSONAL PARTICULARS Recent Photo
Full Name (as in NRIC / Passport) Nationality : *Optional
(*Please underline Surname) Abdurrahman Fadli Indonesia
Identity Card / Passport No. Race : Dialect : Date of Birth (dd/mm/yyyy) Gender
6371021302930002 Banjar Indonesia 13 February 1993 Male
Color of I/C: Blue

Local Address : Komp. Kranggan Permai, Jl.Palem Raya, blok AS 10 No.12A KOTA BEKASI – JATI SAMPURNA
JAWA BARAT
Postal Code ( 17433 )
Overseas Address (if any)

Home Tel No. Mobile Phone No. Email Address :

+62812-89559-883 Abdurrahman.fadly93@gmail.com

NATIONAL SERVICE
Completed National Service:
Yes / No / Exempted / Not liable

EDUCATION / TRAINING
Begin with the 3 highest / most recent educational qualification.
Period Highest Qualifications
School / Institution (mm/yyyy) Course / Major
(GCE “O” Level /
(From Secondary School onwards)
From To Certificate / Diploma /
Degree)

Akademi Keperawatan pandan Harum 2010 2013 Nurse Diploma

Madrasah Aliyah Negeri 2 Banjarmasin 2007 2010 Social Studies High School

EMPLOYMENT HISTORY
Begin with the 3 most recent employer.
Period Last
Positio (mm/yyyy) Drawn
Name of Employer Reason for Leaving
n Basic
From To
Held Salar
y
PT. Mutiara Medical Service Paramedic 2006 2020 165.000/D Contract ends

Rp.3.000.000
RSUD H Badaruddin Nurse 2014 2014 Further Education
/M

Expected salary per month Notice period required Earliest start date

RenalTeam
Private & Confidential
Page 1 of
REFERENCES
Name Contact No. Occupation Relationship Years Known

ADDITIONAL INFORMATION

1. Do you have any obligation to your present company in terms of the bond, study loans, etc.
Yes / No
If yes, please give details:

2. Have you been suffering from any physical impairments or illness that requires you to be on medication now or
for prolong period? Yes / No
If yes, please give details:

(i) Are you a Hepatitis B Carrier? Yes / No

(ii) Are you an HIV Carrier?

Yes / No
*[Successful nursing candidate is required to provide blood test results for items (i) & (ii)]

(iii) Are you pregnant? If yes, please indicate your estimated date of delivery Yes / No

3. Have you ever been convicted in a court of law in any country?

Yes / No
If yes, please give details:

4. Have you ever been suspended or dismissed by an employer?

Yes / No
If yes, please give details:

5. Have you been or are under any financial embarrassment i.e. (a) discharged bankrupt, (b) a judgment debtor, (c)
have unsecured debts and liabilities of more than 3 months of last-drawn pay, (d) have signed a promissory note
or an acknowledgment of indebtedness? Yes / No

If yes, please give details:

6. Have you ever received Awards / Commendations?

If yes, please give details and supporting evidence: (if necessarily, use separate sheet of papers)
Yes / No

7. Have you ever published articles in professional journals or write/ present papers at conferences?
If yes, please give details and supporting evidence: (if necessarily, use separate sheet of
papers) Yes / No
8. Have you ever conducted/ participated in research?
If yes, please give details and supporting evidence: (if necessarily, use separate sheet of papers)
Yes / No

9. Have you ever contributed to committees/ quality improvement projects for the development of your
previous industries?
If yes, please give details and supporting evidence: (if necessarily, use separate sheet of papers)
Yes / No

10. Have you ever participate actively in community/ outreach and voluntary service?
If yes, please give details and supporting evidence: (if necessarily, use separate sheet of papers)
Yes / No

11. Have you ever been employed by VisionHealthOne (VH1) Group of Companies?
If yes, please give details: Yes / No
Centre / Supervisor / Period Employed

12. Did anyone from RenalTeam/VisionHealthOne Group of Companies recommend you?

If yes, please give details: Yes / No
Name / Centre

DECLARATION

I declare that the information furnished in this application is true and correct to the best of my knowledge and belief and that
I have not willfully suppressed any fact(s). If any information given herein is subsequently found to be incorrect, incomplete
or false. I render myself liable for dismissal. Any offer or employment, verbally or otherwise, will be nullified.

I confirm that RenalTeam has made known to me its Personal Data Protection Act Policy (Job Applicant) (“PDPA Policy”)
and I have read and understood it and hereby give my consent to RenalTeam to collect, use and disclose my Personal
Data in accordance with the PDPA Policy and the law.

Signature of Applicant Date

FOR OFFICIAL USE

For Interviewer:

This candidate is: to replace: whose last day of service is .

(please tick) (Name / Centre)

a new headcount for the month of .

Date Joined Salary Offered Remarks:

Interviewed by:
Name of Interviewer Signature / Date
For HR:
Remarks

Name Signature / Date

For Approval:
This application is approved / not approved.

Name Signature / Date

Designation