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APPLICATION FORM 3x4

(Write in Capital Letters)

Please send form to : tenten@gys.co.id / tenten.hidayanti@gmail.com

Position Applied For EXPECTED SALARY Available Starting Date

A. PERSONAL INFORMATION
PERSONAL DATA
Full name: □ Male □ Female
Place / Date of birth:
Address:

City: Post code:

Telephone (residence): Telephone (office):
Hand Phone:
E-mail Address:
I.D. Card Number: Date of Expiry:
Religion: Height / Weight:

FAMILY RECORD
Marital Status : ________________________ Number of Children : ______________________
Husband/Wife Name : ________________________ Age _______ Occupation _______________
Children Name : 1. _________________________________________ Age _____________ M/F
2. _________________________________________ Age _____________ M/F
3. _________________________________________ Age _____________ M/F
Father Name _________________________________ Age _______ Occupation ________________
Mother Name _________________________________ Age _______ Occupation ________________
Contact person in case of emergencies ___________________________ Phone. ___________________

B. EDUCATION

Name and address of school, university From To Degree or

Major Course or Study
or other Training Institutions. (MM/YY) (MM/YY) Certificate
C. RECORD OF PREVIOUS EMPLOYMENT

1. Company Name : _______________________________ Telephone : ________________

Address : _______________________________Position : ________________
Nature of business : ________________________________ Salary : ________________
Employment dates : from ____________ to ____________ Supervisor’s Name : ________________
Duties :
______________________________________________________________________
Reason for leaving : ______________________________________________________________________
2. Company Name : _________________________________ Telephone : ________________
Address : _______________________________Position : ________________
Nature of business : ________________________________ Salary : ________________
Employment dates : from ____________ to ____________ Supervisor’s Name : ________________
Duties : ____________________________________________________________________
Reason for leaving : ____________________________________________________________________
3. Company Name : _________________________________ Telephone : ________________
Address : _______________________________Position : ________________
Nature of business : ________________________________ Salary : ________________
Employment dates : from ____________ to ____________ Supervisor’s Name : ________________
Duties : ____________________________________________________________________
Reason for leaving : ____________________________________________________________________
4. Company Name : _________________________________ Telephone : ________________
Address : _______________________________Position : ________________
Nature of business : ________________________________ Salary : ________________
Employment dates : from ____________ to ____________ Supervisor’s Name : ________________
Duties : ____________________________________________________________________
Reason for leaving : ____________________________________________________________________

REFERENCES (Non – Relatives)

1. Name : ______________________ Phone/Mobile: _________________ Company : _______________

E-Mail : _______________________________________________ Years Known : _______________
2. Name : ______________________ Phone/Mobile: _________________ Company : _______________
E-Mail : _______________________________________________ Years Known : _______________
3. Name : ______________________ Phone/Mobile: _________________ Company : _______________
E-Mail : _______________________________________________ Years Known : _______________

OTHER ACTIVITIES

Name of Organization From date To date Status

D. GENERAL INFORMATION

Are you presently employed?  Yes  No

Have you ever been discharged from employment? If yes, please explain
__________________________________________________________________________________________
Have you any objection to our contacting your previous employers?  Yes  No

Have you had any serious illnesses, injuries or operations within the last five (5) years? If so, please describe
_____________________________________________________________________________________

Language Proficiency
English Not Good Excellent Good Average
Mandarin Not Good Excellent Good Average
Other _______________________

Computer
Word Not Good Excellent Good Average
Excel Not Good Excellent Good Average
Other ________________________

Serious Illness
Lungs Veneral Disease Heart Hypertension
Ayan Diabetes Cancer Other_____________

The Positive in Yourself

STRENGTH WEAKNESS

I certify that all statements made on this application are true and complete to the best of my knowledge.I
understand that misrepresentation or omission when discovered, will subject me to discharge and I hereby
authorize any investigation relating to my work experience, education, or reputation for the purpose of my
application for employment.
Signature,

__________________