Apprentice Applicant Data

 PT. OREMUS BAHARI MANDIRI I declare that the information provided

below is true
 PT. ORELA BAHARI MANDIRI
 ACE MARITIME Your Photograph

 PT. SALDEFENS L.S.

Your Signature
 PT. ALTA MARITIM INDONESIA
Please be filled in handwriting with printed font style
Full Name

Place & Date of Birth

Address
(as a stated on ID Card)

Mobile Phone No Email Adress

For emergency purposes relatives name Contact No
ID card issuance date NIK
Physical data Weight Height Blood Group A B  AB  O
Institution which requisition Major & Level
Reference No. Date:
Student ID Number Issuance date:

Student Status Polbit, Ikatan Dinas  Regular Scholarship .................................................

Have health insurance  Yes  No Expiry Date:
Duration: Months
Apprenticeship program Starting date: up to:
(minimal six months)
Assignment As per management policy:  Agree  No agree ....................................................................
If the last MCU is more than 6 months, the mcu must be done before the
Date of Last MCU
internship begin  Yes, I would  No, I can't do
Please mention a serious
illness that you suffered in
the last 6 months
Please mention diseases that
you often suffer

Item Have or No Reamarks

Laptop  must have
Equipment used during the Wearpack
internship
 must have
Safety Shoes  must have
College uniform  must have

A  Yes  No Date of expiry : To expedite your operational activities,

Driver Licence the apprentices must be able to ride a
C  Yes  No Date of expiry : motorcycle (R2) and a car (R4)

Your goals and expectations

:
after completing your study
The subject you most favorite The subject you most dislike The hobbies you do now

The most kind of food/drink/fruit you like The kind of exercise do you do regularly What you looking for when browsing

HRD – 012/Rev.01-08-09-2021
 SURAT PERNYATAAN

Saya yang tersebut dibawah ini,

NAMA LENGKAP : _________________________________________________

MAHASISWA / SISWA : _________________________________________________
JURUSAN / TINGKAT : _________________________________________________
NOMOR INDUK : _________________________________________________
Dengan ini menyatakan dengan sesungguhnya sebagai berikut,
1) Bahwa saya tidak pernah terlibat dan tidak akan melibatkan diri dalam kegiatan penyalahgunaan
NARKOBA atau obat-obatan terlarang lainnya baik sebagai pengguna, pengedar, maupun
produsen. Apabila dikemudian hari saya terindikasi melakukan aktivitas penyalahgunaan
NARKOBA atau obat-obatan terlarang lainnya, maka saya bersedia diserahkan kepada aparat
yang berwenang (BNN atau POLRI) untuk dilakukan proses hukum lebih lanjut sesuai ketentuan
peraturan perundang-undangan yang berlaku di Indonesia.
2) Bahwa saya bersedia tanpa paksaan untuk mengikuti / mematuhi ketentuan tata-tertib
perusahaan selama saya praktek kerja di PT. Oremus Bahari Mandiri atau groupnya.
3) Bahwa saya akan berlaku sopan terhadap pimpinan, karyawan dan segenap relasi perusahaan,
serta saling menghargai terhadap sesama peserta praktek kerja lainnya.
4) Bahwa saya bersedia untuk berusaha menjadi pelopor protokol kesehatan penanggulangan
covid-19

...................................., .........................................
Saya tersebut diatas

....................................................

HRD – 012/Rev.01-08-09-2021