CONTRACTOR PERSONAL DATA - REV 25-SEPT-2017

To be electronically submitted with electronic copy of each candidate's (at least one of the following): e-KTP/Passport or Education Certific
Dikirim via email dengan melampirkan (minimal salah satu dari): e-KTP/Paspor atau Ijazah atau Akta Kelahiran

No. NAMA LENGKAP

CONTRACTOR EMPLOYEE NAME

1 YOHANES BAPISTA DALA

2 ISKANDAR KBAREK
3 JEFRY EDISON ASYEREM
f each candidate's (at least one of the following): e-KTP/Passport or Education Certificate or Birth Certificate
ah satu dari): e-KTP/Paspor atau Ijazah atau Akta Kelahiran

CONTRACTOR EMPLOYEE INFORMATION

INFORMASI PEGAWAI KONTRAKTO
ALAMAT DI LUAR JOBSITE KOTA PROVINSI

HOME ADDRESS CITY PROVINCE

JL. KEBUN SIRIH TIMIKA PAPUA

JL NURI SEKTORAL TIMIKA PAPUA
JL KETAPANG TIMIKA PAPUA
RACTOR EMPLOYEE INFORMATION (TO BE FILLED BY CONTRACTOR) - SAME AS KTP/PASSPORT
INFORMASI PEGAWAI KONTRAKTOR (DIISI OLEH KONTRAKTOR) - SESUAI KTP/PASPOR
TANGGAL LAHIR TEMPAT LAHIR JENIS KELAMIN NO. HP

DATE OF BIRTH PLACE OF HANDPHONE NO.

GENDER
(MM/DD/YY) BIRTH (08XXXXXXXXXX)
01/01/1987 MAUMERE LAKI-LAKI 081359274670
31/10/1976 BIAK LAKI-LAKI 081248189275
18/06/1984 ABEPURA LAKI-LAKI 081247178631
 1ST PRIORITY (PRIOR TO BACKGROUND CHECK AND MCU)
ORT PRIORITAS 1 (SEBELUM PEMERIKSAAN LATAR BELAKANG DAN MCU)

NASIONAL/EXPAT/PAPUA/7-
KEWARGANEGARAAN NO. KTP/PASPOR
SUKU
NATIONAL/EXPAT/PAPUAN/
NATIONALITY KTP / PASSPORT NO.
7-TRIBES
NASIONAL INDONESIA 9109010101870011
PAPUA INDONESIA 9106123110730001
PAPUA INDONESIA 9109011806840011
BACKGROUND CHECK AND MCU)
RIKSAAN LATAR BELAKANG DAN MCU) REPLAC
KATEGO
EMENT STATUS UID
RI
TYPE
LOKASI MCU UID PT FI (PERMANENT/
PENGGA
(VR- TEMPORARY)
NTIAN
PTFI,
MCU LOCATION PT FI ASSIGNED UID (IF APPLICABLE)
VR-
KUALA KENCANA Contracto
Project PERMANEN
r,
KUALA KENCANA Project PERMANEN
Attrition,
KUALA KENCANA Projects)
Project PERMANEN
 CONTRACT INFORMATION (TO BE FILLED BY CRP)
INFORMASI KONTRAK (DIISI OLEH CRP)
NO. KONTRAK NAMA PERUSAHAAN LOKASI KERJA USER

CONTRACT PT FI WORK LOCATION

COMPANY NAME PT FI CRP
NUMBER AREA
PT KIAVANA LESTARI Dave Jones TRANSPORTATION
PT KIAVANA LESTARI Dave Jones TRANSPORTATION
PT KIAVANA LESTARI Dave Jones TRANSPORTATION
LLED BY CRP)
EH CRP)
DIVISI DEPARTEMEN NAMA JABATAN

DIVISION DEPARTMENT JOB TITLE

TRANSPORTATION & L/L FACILITY MANAGE TRANSPORTATIONHELPER

TRANSPORTATION & L/L FACILITY MANAGE TRANSPORTATIONHELPER
TRANSPORTATION & L/L FACILITY MANAGE TRANSPORTATIONHELPER
 GOLONGAN
KODE POS AGAMA SUKU STATUS PERKAWINAN
PEKERJA
EMPLOYEE
MARITAL STATUS
TYPE POST CODE RELIGION TRIBE
(Married/Single)
(Staff/Pratama)
NON STAFF 99910 KATHOLIK NTT SINGLE
NON STAFF 99910 KRISTEN BIAK MARRIED
NON STAFF 99910 KRISTEN BIAK SINGLE
 CONTRACTOR EMPLOYEE I
INFORMASI PEGAWAI
TANGGAL PERNIKAHAN NO. NPWP NO. BPJS KETENAGAKERJAAN (JIKA ADA)

DATE OF MARRIAGE NPWP NO. BPJS LABOUR NO. (IF APPLICABLE)

09025423899
15/09/2003 20069809638
20069809927
CONTRACTOR EMPLOYEE INFORMATION (TO BE FILLED BY CONTRACTOR)
INFORMASI PEGAWAI KONTRAKTOR (DIISI OLEH KONTRAKTOR)
TEMPAT PENERIMAAN TUJUAN CUTI
NAMA ALAMAT
POINT OF
POINT OF HIRE NAME ADDRESS
TRAVEL
TIMIKA MARIA SUSANTI JL.MOTOPAI SP3
JL NURI BELAKANG 3
TIMIKA YAHYA
RAJA
TIMIKA DELLA STEVANI JL WOWOR
 2ND PRIORITY (PRIOR T
PRIORITAS 2 (SEBELUM
EMERGENCY CONTACT
KOTA PROVINSI KODE POS NO. TELP RUMAH NO. HP
CITY PROVINCE POST CODE HOME PHONE NO. HANDPHONE NO.

TIMIKA PAPUA 99910 081240016037

TIMIKA PAPUA 99910 082290619933
TIMIKA PAPUA 99910 085244611956
2ND PRIORITY (PRIOR TO UID ISSUANCE)
PRIORITAS 2 (SEBELUM PEMBUATAN UID)

TANGGAL AKHIR KONTRAK UID PT FI YANG DIGANTIKAN

HUBUNGAN KENGAN KARYAWAN
CONTRACT END PT FI ASSIGNED UID BEING
RELATIONSHIP TO EMPLOYEE
DATE(MM/DD/YY) REPLACED
ADEK KANDUNG
SAUDARA SEPUPU
ADEK KANDUNG
 CONTRACT INFORMATION (TO BE FILLED BY CRP)
INFORMASI KONTRAK (DIISI OLEH CRP)
TANGGAL KEDATANGAN DI JOBSITE TAMU BISNIS STATUS DI JOBSITE

DATE REQUIRED ON SITE ONSITE STATUS

BVTR? (Y/N)
(MM/DD/YY) (Single/Family)
 RENCANA TANGGAL KEDATANGAN DI PT
HAK TIKET AIRFAST
FI COW
PLANNED ARRIVAL DATE IN PT FI COW
AIRFAST ELIGIBILITY (Y/N)
(MM//DD//YY)
 LICENSING INFORMATION (TO BE FILLED BY CRP)
INFORMASI LICENSING (DIISI OLEH CRP)
REQUIRED LICENSE
MEMBUTUHKAN LICENSE?
LICENSE KRITIKAL
REQUIRE LICENSING? (Y/N) CRITICAL LICENSE
 ILLED BY CRP)
OLEH CRP) 1ST PRIORITY
REQUIRED LICENSE
DATA COMPLETED FOR
LICENSE NON-KRITIKAL
BACKGROUND CHECK AND MCU
NON-CRITICAL LICENSE

INCOMPLETE
INCOMPLETE
INCOMPLETE
 2ND PRIORITY
DATA COMPLETED FOR UID
ISSUANCE

COMPLETED
COMPLETED
COMPLETED