APPLICATION FORM

It is Universitas Siber Asia policy that all employment is based on equal opportunity, individual performance and
competencies. All information will be treated strictly confidential.

I. PERSONAL INFORMATION
POSITION APPLIED UNSIA DEPUTY DIRECTOR of MARKETING BUREAU

1. FULL NAME Mario Candra

DATE OF BIRTH ( 11/05/1983 KOMPLEK UNILEVER BLOK A8/NO.8 RT 05 / RW 09, MERUYA

2. dd / mm / yy ) SELATAN, KEMBANGAN, JAKARTA BARAT
3. PLACE OF BIRTH MADIUN 12. RESIDENTIAL ADDRESS
4. SEX MALE
11650
5. ZIP CODE
CIVIL STATUS 13. TELEPHONE NO.
KOMPLEK UNILEVER BLOK A8/NO.8 RT 05 / RW 09, MERUYA
6. NATIONALITY SELATAN, KEMBANGAN, JAKARTA BARAT
14. PERMANENT ADDRESS
7. HEIGHT (m)
8. WEIGHT (kg) ZIP CODE 11650
9. BLOOD TYPE 15. TELEPHONE NO.
mario_candra@yahoo.co.id
10. DRIVING LICENSE 16. E-MAIL ADDRESS (if any)
11 RELIGION MOSLEM 17. CELLPHONE NO. (if any) 082320192599
II. FAMILY BACKGROUND
21. NAME OF CHILD (Write full name and
18. SPOUSE'S list all) DATE OF BIRTH ( dd / mm / yy )
FULL NAME ROBBIE SATRIA ARISAPUTRA 16/12/2014
DATE OF BIRTH JULIAN CANDRA ARISAPUTRA
(dd/ mm/ 06/07/2017
yy)
OCCUPATION / /
EMPLOYER'S. NAME / /
BUSINESS ADDRESS / /
TELEPHONE NO. 22. NAME OF BROTHERS / SISTERS OCCUPATION COMPANY
19. FATHER'S LUSI KUSUMASARI STAFF EQUITY LIFE
FULL NAME A TRIWIJAYANTI HOUSEWIFE

OCCUPATION

20. MOTHER'S
FULL NAME

OCCUPATION

(Continue on separate sheet if

III. EDUCATIONAL BACKGROUND
HIGHEST GRADE/ INCLUSIVE DATES OF SCHOLARSHIP/
23. MAJOR YEAR
NAME OF SCHOOL LEVEL/ ATTENDANCE ACADEMIC
LEVEL (Write GRADUATED
(Write in full) UNITS EARNED (if HONORS
in full) (if From To
not graduated) RECEIVED
ELEMENTARY SDN KARTOHARJO I graduated)
1996
JUNIOR HIGH SLTPN 01 MADIUN 1998
SENIOR HIGH SMUN 02 MADIUN 2001
DIPLOMA
UNIVERSITAS SANATHA 2007
BACHELOR DHARMA
MASTER
DOCTOR
(Continue on separate sheet if
necessary) Page 1 of 3
IV. WORK EXPERIENCE (Include private employment. Start from your current job)
24.
INCLUSIVE DATES
(dd /mm / yy) STATUS OF
DEPARTMENT - CURRENT/LAST
POSITION TITLE EMPLOYEE REASON FOR LEAVING
COMPANY SALARY
No From To contract/permane
nt

(Continue on separate sheet if

V. OTHER INFORMATION necessary)
25 26. 27.
. SPECIAL NON-ACADEMIC ACHIEVEMENT/ MEMBERSHIP IN ASSOCIATION / ORGANIZATION
SKILLS / RECOGNITION/ AWARD (Write in full)
HOBBIES (Write in full)

(Continue on separate sheet if

necessary)
VI. TRAINING PROGRAMS (Start from the most recent training)
28

TITLE OF SEMINAR / INCLUSIVE DATES OF ATTENDANCE ( dd

CONFERENCE / WORKSHOP/ / mm / yy ) CONDUCTED / SPONSORED BY
SHORT COURSES (Write in full)
(Write in full)
From To

/ /

/ /

/ /

/ /

(Continue on separate sheet if

necessary)
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No QUESTION YES NO REMARKS
29. Have you ever applied to Universitas Siber Asia before? When and for what position/job> NO
30.
Besides applying to Universitas Siber Asia, which companies do you also apply to? For what position/job? NO

31. Are you bound by a contract with the company you are working for now? NO

32. Do you have any part time job? Where and what position? NO

33. Do you have any objection if we ask a reference from the company you have worked for? YES

34. Do you have any friends / families working in this company? Please state NO

35 Have you ever had a serious disease, chronic, accident or operation? When and what type? NO

36 Do you have color blindness? NO

Have you ever been imprisoned, convicted or investigated by the police in relation with crime? If
37 yes, please explain. NO

Have you ever been convicted of any crime or violation of any law, decree, ordinance or
38 regulation by any court or tribunal? NO

39 How is your english capacity? Have taken TOEFL or IELTS test? (Please mention test date and score) 2006,
SCORE 225
40 If you are accepted, do you mind supporting other bureau within Universitas Siber Asia, if required? NO, I
DON’T MIND

41 If required, do you agree to work overtime during working days? YES, I DO

42 If required, do you agree to work during the weekend and/or holidays?YES, I DO

43 Do you agree to take a job psychological test? YES, I DO

No QUESTION ANSWER
44. What type of jobs/positions that you do not like? THERE IS NOT ANY

45. How much is your monthly salary and benefits/facilities you receive now? IDR.8.000.000 (NET)
(Please note Net or Gross)

46. If you are accepted, how much gross salary and what benefits/facilities do you
expect? (Before Tax) IDR.8.000.000 – IDR.10.000.000

47.
If you are accepted, when you start working?
REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
48.

NAME POSITION / JOB RELATION WITH YOU TEL. NO.

Mario Candra,S.T. UNSIA DEPUTY DIRECTOR of MARKETING BUREAU 082320192599

49 Disclaimer Statement
.
I declare under oath that statements in this Application Form has been accomplished
by me, and is a true, correct and complete
statement pursuant to the provisions of pertinent laws, rules and regulations of the
Republic of Indonesia. I understand that the false information in this application shall be PHOTO
considered sufficient for dismissal from employment. I also authorize the agency head
/ authorized representative to verify / validate the contents stated herein. I trust that
this information shall remain confidential.

SIGNATURE (Sign inside the box)

ADDITIONAL INFORMATION DATE ACCOMPLISHED

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