EMPLOYMENT APPLICATION FORM

POSITION APPLICATION

1. POSITION APPLIED : NURSE DATE OF INTERVIEW 21-Apr-21

2. HOW DID YOU FIND THIS VACANCY ?

LinkedIn Recruitment Agency/Headhunter Direct Application Others, please mention ____________

Facebook √ Jobstreet Staff Referral
√

PERSONAL DATA
1. FULL NAME Ahmad Rofiq Singgih Surya Medari
2. SEX Man
3. PLACE DATE OF BIRTH Tuban
4. DATE OF BIRTH 14-Nov-93
5. MARITAL STATUS Single
6. RELIGION Islam
7. NATIONALITY Indonesia
8. ID CARD/PASSPORT NUMBER 3523111411930002
9. NPWP NUMBER -
10. SOCIAL SECURITY NUMBER (BPJS KETENAGAKERJAAN) 19044693778
11. CURRENT ADDRESS Jl.Banyu Urip Gang VII no.7B-Sawahan-Surabaya

12. PERMANENT ADDRESS (AS PER ID CARD) Dsn.Kenongo lor rt 003 rw 006,Desa kenongosari-soko-tuban

13. CONTACT NUMBER MOBILE 1 082245965407

MOBILE 2
RESIDENCE
14. EMAIL rofiqsinggih62@gmail.com

15. SOCIAL MEDIA LINKEDIN

FACEBOOK (Ahmad Rofiq Singgih)
INSTAGRAM (Ahmadrofiqs.s.m)
TWITTER

FAMILY INFORMATION (for married individual, please fill in spouse & children data)
No Name Sex Relationship Education/ Occupation/ Company
1 Lumaeni woman mother -
2 Ahmad Rofiq Singgih Surya Medari man child undergraduate nursing
3 Icho Tubagus Ahmad Saikon man child rekam medik

PARENTS AND RELATIVES DATA (for single individual, please fill in family members information)
No Name of Parents and Relatives Sex Relationship Date of Birth City Education/ Occupation

EMERGENCY CONTACT
No Name Relationship Address Phone Number(s)

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 1

 Dsn.Kenongo lor rt 003 rw
1 icho brother 006,Desa kenongosari- 085338511939
soko-tuban

FORMAL EDUCATION
Qualification
No School/ Institution City Year of Graduation Major Obtained GPA
1 SDN Kenongosari Tuban 2000 - 2006
2 SMP Negeri 4 Bojonegoro Bojonegoro 2006 - 2008
3 SMK BIMA Bojonegoro Bojonegoro 2008 - 2011 RPL
4 STIKES ICSADA Bojonegoro Bojonegoro 2011 - 2016 Keperawatan

LANGUAGE
No Language Spoken Written Reading
1 Indonesia High High High (Low/ Moderate/ High)
2 english moderate Low Low (Low/ Moderate/ High)
(Low/ Moderate/ High)

PROFESSIONAL LICENSES OR CERTIFICATION

No Name of Certification Name of Institution Years Obtained
1 Basic Trauma Cardiac Life Suport PPNI JATIM 2021
2 Hiperkes PT.PHC 2020
3 TOEFL ELFAST 2016

WORK EXPERIENCE
Current Company
Rumah Sakit Lapangan Indrapura
Company Name
Company Address JL.krembangan no.17
Latest Position
Ners

Date (DD/MM/YYYY) Start Date 29 mei 2020 End Date to date

Starting Salary 5,000,000

Latest Salary 5,000,000

Reason for leaving looking for a permanent job

yes, 082139840983
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why

Achievement(s)

1. Award from the Ministry of Health as a volunteer nurse

2. Award from the governor of East Java as a nurse

Previous Company
Rumah Sakit William booth
Company Name
Company Address jl.diponegoro no.34 darmo kec.wonokromo-surabaya
Latest Position
ners

Date (DD/MM/YYYY) Start Date desember 2018 End Date februari 2020

Starting Salary 3,500,000

Latest Salary 4,200,000

Reason for leaving at home because of the covid-19 pandemic

No, because I was out of William Booth Hospital
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why

Achievement(s)

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 2

Previous Company

Company Name
Company Address
Latest Position

Date (DD/MM/YYYY) Start Date End Date

Starting Salary
Latest Salary

Reason for leaving

May we contact this current/ previous employer directly?

If yes, please provide name, contact number If not, please explain why

Achievement(s)

ORGANIZATION STRUCTURE
(please draw organization structure showing your position in your current company)

REFERENCES
List two person NOT related to you, who are familiar with your character, background or work performance (preferably your direct supervisor)

Name : Contact No :
Company : Job Position :

Years Known :
Relationship :

Name : Contact No :
Company : Job Position :

Years Known :
Relationship :

CURRENT DETAILS OF SALARY AND BENEFITS

1. Monthly basic salary gross 5,000,000 IDR
2. Eligible for over time ? No ( Yes / No )
If yes, monthly average ?
3. Allowances
Meal
Transportation IDR
Phone/ Handphone IDR
Others IDR
4. Loan facilities Type of Loan Housing Car Personal
Outstanding Amount Max Limit
Interest per Year % Outstanding Period (months/ years)
Repayment Methods (months/ years)
5. Annual Leave (Days)
6. Annual Bonus :
THR (Festive Allowance) IDR
Performance Bonus IDR
Others, please explain IDR

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 3

7. Medical Benefits Cashless Reimburstment
Out Patients (Per Year) IDR
In Patients (Room & Board) IDR
8. Life Insurance IDR
9. Other Benefits, Please Explain:

COMPENSATION BENEFIT EXPECTATION & COMMENCEMENT

1. Monthly salary (Gross) 5,000,000 IDR
2. Benefits / Others
3. If you are offered employment with us
Immediately
when can you start work (or notice period) ?

DECLARATIONS AND AUTHORIZATIONS

1. Do you have any family members; as an employee, who working in this company? (Yes/ No) NO
If yes, please state the name of the employee, designation and relation.

2. Have you ever been dismissed or suspended from any position, or subject to internal disciplinary action by any of your
previous employers? (Yes/ No) NO
If yes, please state where, when and cause

3. Have you ever been convicted of a criminal offence anywhere in the world, excluding convictions that have been set aside
or quashed? (Yes /No) NO
If yes, please provide details.

Disclosure of a criminal record will not necessarily disqualify you for employment. However failure to disclose such information may result in disqualification of your
application of dismissal from employment at MAYAPADAHEALTHCARE GROUP
4. Have you ever apply/ work in MAYAPADA HEALTHCARE GROUP? (choose one) (Yes/ No) NO
If yes, When ? For position ?
Where Last selection stage (for apply)

5. Are you currently holding any position in any political party or a candidate for any political office? NO
If yes, please provide the detail of position and political party and your joining date to that political party and the position that you are running for as candidate.

6. Is there any member of your immediate family an official or any government agency, an employee of any government agency,
an official of political party, or a candidate for political office? NO
If yes, please states the detail of the name, position/office held and the family relationship. Immediate family means husband, wife, children, mother, father, siblings.

7. Do you have any other job or business activities outside the current employment? NO
If yes, please provide the detail including name of enterprise, type of business, position and starting year of the position.

I certify that all the information provided on this application is true and complete to the best of my knowledge.
I understand that any false information or omission may lead to disciplinary action or summary dismissal without any compensation.
I authorize MAYAPADA HEALTHCARE GROUP to verify all information provided in this application, including employment history, educational background and references.
I authorize my previous employers and references indicated above to release any information they may have about me.
MAYAPADA HEALTHCARE GROUP will only use information collected in connection with my employment with MAYAPADA HEALTHCARE GROUP.

Ahmad Rofiq Singgih Surya Medari, S.Kep., Ns

Signature & Name

To the extent required by law, you may request to review and correct personal data through the HR Department.

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 4