PT.

SRIWIJAYA BARA PRIHARUM

APL Tower @ Central Park, 25th Floor Unit T8. Jalan Let. Jend. S. Parman Kav. 28.
Jakarta Barat 11470. Indonesia.
Telp: +62... Fax: +62…

CANDIDATE INFORMATION FORMS

Strictly Confidential !!!

Please fill in this form completely in order to be further processed.

Position Applied: Junior QA/QC

PERSONAL INFORMATION
Title : ☐ Mr. ☐ Miss. ☐ Ms. ☐ Mdm. ☐ Others
Full Name : Lorensius Vemo Viandaru
Nick Name : Vemo
Gender : Male
Place & Date of Birth : Tugumulyo, 22 August 1998
Religion : Katholik
Nationality : Indonesia
Ethnic : Javanese
Marital Status : ☐Single ☐ Married ☐ Widowed ☐ Divorce
No. Of Dependent : -
E-mail Address : vemovian16@gmail.com
Mobile Telephone No. : 082183113925
Nomor Pokok Wajib Pajak (NPWP) : -
Present Residential Address: Previous Address (If current address is less than 3 years):
Jl. Raya Mataram, RT 2/Dusun 3, Kecamatan
Tugumulyo, Musi Rawas, Sumatera Selatan
☐Owned – No Loan ☐ Owned - With Loan ☐ Owned – No Loan ☐ Owned - With Loan
☐ Rented ☐ Employer’s ☐ Rented ☐ Employer’s ☐ Rented ☐ Rented
Present Home Phone No.: - Home Telephone No.:
Length Of Stay : ..…19…..Year (s) … .0…..Month (s) Length of Stay : ……..Year (s) …….... Month (s)

PERSONAL IDENTITY
Type: Number: Place Of Issue: Date Of Issue: Date Of Expiry:
Passport - - - -
Identity Card (I.C) 1605012208980005 Musi Rawas 05/08/2017 Lifetime
Driving License - - - -

Candidate Information Form Page 1 of 8 2/6/21

 SPOUSE DETAILS
Full name :
Place & Date of Birth :
Nationality :
Ethnic :
Religion :
Occupations :
Email Address :
Present Residential Address: Previous Address (If current address is less than 3 years):

☐ Owned – No Loan ☐ Owned - With Loan ☐ Owned – No Loan ☐ Owned - With Loan
☐ Rented ☐ Employer’s ☐ Rented ☐ Rented ☐ Employer’s ☐ Rented
Present Home Phone No.: Mobile Phone No.:
Length Of Stay : ..……..Year (s) … ….…..Month (s) Length of Stay : ……..Year (s) …….... Month (s)

CHILDREN INFORMATION
1. Full Name :
Place & Date Of Birth :
Gender :
Last Education :
Occupation :
2. Full Name :
Place & Date Of Birth :
Gender :
Last Education :
Occupation :
3. Full Name :
Place & Date Of Birth :
Gender :
Last Education :
Occupation :
4. Full Name :
Place & Date Of Birth :
Gender :
Last Education :
Occupation :
5. Full Name :
Place & Date Of Birth :
Gender :
Last Education :
Occupation :

ACADEMIC INFORMATION
Candidate Information Form Page 2 of 8 2/6/21
 From – to
Diploma
(States month & Schools, Colleges, Universities Major GPA (Yes / No)
year)
Geological
08/2016 – 08/2020 Sriwijaya University
Engineering
3.47 / 4.00 YES
Science
07/2013 – 07/2016 St. Yosef Lahat Senior High School
Program
60,5/100 YES

07/2010 – 07/2013 Xaverius Tugumulyo Junior High School - 68,0/100 YES

07/2004 – 07/2010 Xaverius Tugumulyo Elementary School - - YES

07/2003 – 07/2002 Xaverius Tugumulyo Pre-Primary School - - YES

SEMINAR / COURSE / WORKSHOP

From – To Topic Organizer & Location
Certificate
(States dates, month & year) (Yes / No)

DRILLING DATA ACQUISITION ON

17 OCTOBER 2020 W OYLA & MGEI SC UNSRI YES
COAL EXPLORATION
SEMINAR NASIONAL TEKNOLOGI A DITAMA INSTITUTE OF TECHNOLOGY
12 JULY 2020 YES
KEBUMIAN & KELAUTAN SURABAYA
GEOLOGI U NTUK PEMBANGUNAN DAN PENGURUS DAERAH I KATAN AHLI
12 SEPTEMBER
KESEJAHTERAAN M ASYARAKAT GEOLOGI INDONESIA (S UMATERA NO
2019
SUMATERA SELATAN SELATAN )
INTRODUCTION TO DRILLING FLUID
STUDENT S ECTION OF I NDONESIA
29 MARCH 2018 TECHNOLOGY FOR OIL & GAS NO
A SSOCIATION OF GEOLOGIST
EXPLORATION
17 FEBRUARY STUDENT S ECTION OF I NDONESIA
DEWATERING P ROCESS ON CBM NO
2018 A SSOCIATION OF GEOLOGIST
CURRENT STATUS OF EXPLORATION FOR
22 OCTOBER 2016 HMTG “SRIWIJAYA ” YES
MINERAL & ENERGY RESOURCES

WORKING EXPERIENCE
* Fill from current, previous to first position
Commence Date –
Date Of Completion Name Of Employer Job Category
(States dates, month & year)

Candidate Information Form Page 3 of 8 2/6/21

 EMPLOYMENT DETAIL
Date of Employment : Date Employment Ended :
Name Of Company
Office Address
Tel No.
Nature Of Business
Position Held
Years Of Service
Report Directly To Name /
Total Number Of Employees
Number Of Sub-Ordinates ________ Persons
o
o
o
Job Description o
o
o
o
Achievement
☐ Through Advertisement ☐ Others
How Did You Get Employed
☐ Recommendation
Last Drawn Salary
Reason For Leaving

ORGANIZATION STRUCTURE
*) Please draw your position within current/latest organization (including two levels up & below)

Candidate Information Form Page 4 of 8 2/6/21

 Date of Employment : Date Employment Ended :
Name Of Company
Office Address
Tel No.
Nature Of Business
Position Held
Years Of Service
Report Directly To
Total Number Of Employees
Number Of Sub-Ordinates



Job Description




Achievement
☐ Through Advertisement ☐ Others
How Did You Get Employed
☐ Recommendation
Last Drawn Salary
Reason For Leaving

Date of Employment : Date Employment Ended :

Name Of Company
Office Address
Tel No.
Nature Of Business
Position Held
Years Of Service
Report Directly To
Total Number Of Employees
Number Of Sub-Ordinates







Achievement
☐ Through Advertisement ☐ Others
How Did You Get Employed
☐ Recommendation
Last Drawn Salary
Reason For Leaving

Date of Employment : Date Employment Ended :

Candidate Information Form Page 5 of 8 2/6/21

 Name Of Company
Office Address
Tel No.
Nature Of Business
Position Held
Years Of Service
Report Directly To
Total Number Of Employees
Number Of Sub-Ordinates







Achievement
☐ Through Advertisement
How Did You Get Employed How Did You Get Employed
☐ Recommendation
Last Drawn Salary

Reason For Leaving

FINANCIAL INFORMATION
I hereby declare that:
☐ I do not have any non-bank organization Outstanding debts.
☐ I do have non-bank organization outstanding debts as per below details.
Type of Facility : Loan Outstanding Monthly
☐ Bank ☐ Housing Loan (HL) Amount Balance instalmen
☐ Finance Company ☐ Car Loan (CL) (Rp) : (Rp) : t
☐ Others (Rp) ;
☐ Personal Loan (PL)
☐ Others

1.
2.
3.
Do you own Bank’s Credit Card / Accounts?
Card Company:- Member Since :- Card No. :-
1.
2.
3.
Do you own ☐ Car (s) ☐ Motorcycle (s) :
Leasing Company:-

ADDITIONAL INFORMATION
SPECIAL ACTIVITIES
Candidate Information Form Page 6 of 8 2/6/21
 From – To Name of Organization Place Position
2017 – 2018 STUDENT SECTION OF INDONESIA Palembang Staff of Public
ASSOCIATION OF GEOLOGIST Relation Division
2018 - 2019 STUDENT SECTION OF INDONESIA Palembang Head of Public
ASSOCIATION OF GEOLOGIST Relation Division

LANGUAGE SKILLS
Language Reading Writing Speaking Understanding
Bahasa Indonesia E E E E
English G G F G

Notes: E = Excellent G = Good F = Fair P = Poor

OTHER PERSONAL INFORMATION

Computer Proficiency
Other Skills & expertise
Interest
(Program/Language: ArcGIS, Map Source, Microsoft Office, Global
Mapper, Surfer, AutoCAD, Micromine,)
Geological Mapping, Modeling, Seismic & Logging Interpretation
Basketball, Jogging, Writing, Cycling

EMERGENCY CONTACT
Name of relative / friends not staying with you: Relationship: Sister Email Address:
Veronika Vety Mei Cahyani vetty.rumble90@gmail.com
Residence Address: Office Address:
Duta Asri Residence No 5Ca, H. Masduki Street, SMAK 1 Penabur, Bandung
Parongpong District, West Java 40559
Residence Telephone No.: 081298812695 Office Telephone No.: -

OTHER INFORMATION
Core competencies:
Have you been dismissed or suspended from any position? ☐ Yes ☐ No.
If so, state details :

Are you engaged in any business? ☐ Yes ☐ No.

What kind of business?-
Current Salary: - Expected salary: Rp.4.500.000
Details of current remuneration package:-

Do you have any other sources of income? ☐ Yes ☐ No.

If so, state details :

When are you available for work: after 3-5 days Notice Period:-

FAMILY DETAILS

Candidate Information Form Page 7 of 8 2/6/21

 Highest
Relationship Name F/M Age Occupation
Educational
Father Agustinus Rinantoko alm. M - Associate Degree -
Mother M.M. Surati F 62 Junior High School Housewife
1. Mariano Very Vian Candra M 43 Bachelor Degree Private Employee
2. Maria Vivi Etia Sofya F 39 Associate Degree Housewife
Brother 3. Veronika Vety Mei Cahyani F 29 Bachelor Degree Teacher
(s) / 4. Lorensius Vemo Viandaru M 22 Bachelor Degree Fresh Graduate
Sister (s) 5.
6.
7.

You have ___4 (four)___brother (s) / sister (s) and are the ____Youngest____child in the family.

EMPLOYMENT REFERENCE
Name: Stevanus Nalendra Jati S.T., M.T. Name:
Position: Lecturer Position:
Company Name: Sriwijaya University Company Name:
Company Address: Jl. Srijaya Negara, Bukit Besar, Palembang Company Address:
(30139)
Nature of Relationship: Thesis Supervisor Nature of Relationship:
Tel. No. (Office) : (0711) 370 178/352 870 Tel. No. (Office) :
Tel. No. (Res) :- Tel. No. (Res) :
Mobile No. : 08117121410 Mobile No. :
E-mail : s.nalendra@unsri.ac.id E-mail :

MANDATORY
* Please submit a photocopy of IC (Kartu Tanda Penduduk) together with anyone or more of the following document.
☐ Latest Salary Slip ☐ Latest Tax Return With IRD Receipt

☐ Personal Bank Statement (showing salary credited) ☐ Latest Jamsostek

By signing this form I certify that the information in this application is factually correct, honestly presented, and is an accurate
account of my professional experience. Should it be untrue, I would be prepared for a dismissal at any time without any
conditions.

Signature: _______________________________ Date: 14th November 2020

Full Name: Lorensius Vemo Viandaru

Candidate Information Form Page 8 of 8 2/6/21