Application Form

photo
Position Applied For :
Date of Application :

PERSONAL INFORMATION
Full Name
Home Address
Telephone
Business Residence Mobile e-mail Address
Religion
Sex
Date/Place Of Birth
Marital Status
Nationality
Marital status Name of spouse Occupation of Spouse Number of Children

Parents Occupation of Parents Name of Brother(s) & His/Her Occupation

Sister(s)

Have you ever been employed by Gunung Sewu or any of the subsidiaries? Y N
If "Yes" Please indicate the period, position and company

Have you previously applied for employment with Gunung Sewu or any of the subsidiaries?
Y N
If "Yes" when and for what position?

How were you referred to Gunung Sewu or Baramutiara Prima?

Agency School Advertisement Direct Contact Employee Other

Please name any relatives or friends currently or previously employed by company

Name: Relationship:

What are you recreational activities and hobbies?

Application Form BARAMUTIARA PRIMA Page 1 of 5

 Do you have any special skills or aptitudes e.g. Language, manual skills, public speaking etc?

What software application are you fluent with?

What business and professionals associations do you belong to?

EDUCATIONAL BACKGROUND (Complete from higher level)

Name of University / Academy Period Qualification

Are you currently studying? If yes, please state the type of course, name of course, name of institution and when you
will be completing:

WORK HISTORY
Year Position Company Reason for leaving Renumeration Package

Have you ever been suspended or requested to resign from any employment? Y N
If yes, when and why?

Application Form BARAMUTIARA PRIMA Page 2 of 5

 Please state your current / latest key duties & responsibilities, as well as your company's organization structure.

Key Duties & Responsibilities Organization Structure

How much is your current salary? And what are the allowances and benefits that you receive?

EXPECTATION
What salary do you expect for this position?

When would you be available to take up this position?

Would you consider a position in another city in Indonesia?

Y N If yes, why?

Application Form BARAMUTIARA PRIMA Page 3 of 5

 Other than in Baramutiara Prima, which other companies are you applying to?

MEDICAL HISTORY
Do you suffer from any illnesses whose effect impair your ability to handle the job you are applying for?

Y N

If yes please describe:

REFERENCES

Baramutiara Prima may inquire at will To check with applicant before enquiring

Business Reference Title Company Telephone

Character / Personal Reference Relationship Address Telephone

CERTIFICATION
I cerify that I understand the questions and the answer and information given herein are true and complete to the best
of my knowledge. In the event of employment, I understand that false or misleading information given in my applicatio
or interview(s) may result in discharge. I understand, also, that I am required to abide by rules and regulations
of the company.

Date: Signature:

Application Form BARAMUTIARA PRIMA Page 4 of 5

Application Form BARAMUTIARA PRIMA Page 5 of 5