EMPLOYMENT APPLICATION FORM

POSITION APPLICATION

1. POSITION APPLIED : Ners DATE OF INTERVIEW 1 Juli 2024 Zoom Meeting

2. HOW DID YOU FIND THIS VACANCY ?

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

Instagram
Facebook Jobstreet Staff Referral

PERSONAL DATA
1. FULL NAME Atika Nur Huda
2. SEX Perempuan
3. PLACE DATE OF BIRTH Bakau
4. DATE OF BIRTH 06 Oktober1995
5. MARITAL STATUS Belum Kawin
6. RELIGION Islam
7. NATIONALITY Indonesia
8. ID CARD/PASSPORT NUMBER 6302134610950000
9. NPWP NUMBER 96.485.823.7-734.000
10. SOCIAL SECURITY NUMBER (BPJS KETENAGAKERJAAN) 22074818273
11. CURRENT ADDRESS Jl. Sultan Adam Komplek Kelapa Gading RT 23/RW 02 No 23A Banjarmasin Utara
Kota Banjarmasin Provinsi Kalimantan Selatan 70123
12. PERMANENT ADDRESS (AS PER ID CARD) Jl. Ratu Intan RT 001/RW 001 Desa Bakau Kecamatan Pamukan Utara
Kabupaten Kotabaru Provinsi Kalimantan Selatan 72169
13. CONTACT NUMBER 085250729856

14. EMAIL atikasamihim@gmail.com

15. SOCIAL MEDIA Instagram : _atikanh_

FAMILY INFORMATION (for married individual, please fill in spouse & children data)
No Name Sex Relationship Education/ Occupation/ Company
1. Atika Nur Kamilah Perempuan saudara Kandung Mahasiswa

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
1 Abdul Kadir Laki-laki Ayah 15 Juni 1971 Kotabaru Wiraswata
2 Norlian Perempuan Ibu 28 Februari 1968 Kotabaru Pedagang

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 1

EMERGENCY CONTACT
No Name Relationship Address Phone Number(s)
1 Atika Nur Kamilah Saudara Kandung Kotabaru 082252835207
2 Norlian Ibu Kotabaru 082158002111

FORMAL EDUCATION
Qualification
No School/ Institution City Year of Graduation Major GPA
Obtained
Sangat
1 S1 Keperawatan Banjarmasin 2018 3.31
Memuaskan
Sangat
2 Profesi Ners Banjarmasin 2020 3.70
Memuaskan

LANGUAGE
No Language Spoken Written Reading
1 Bahasa Indonesia Moderate Moderate Moderate (Low/ Moderate/ High)
2 Bahasa Inggris Low Low Low (Low/ Moderate/ High)
(Low/ Moderate/ High)

PROFESSIONAL LICENSES OR CERTIFICATION

No Name of Certification Name of Institution Years Obtained
1. BTCLS Gadar Medik Indonesia 2021
Gawat Darurat Anastesi dan Terapi
2 RSUD Dr. Soetomo 2019
Intensif

WORK EXPERIENCE
Current Company

Company Name RS Islam Banjarmasin

Company Address Jl. S. Parman No. 88 RT. 24, Kota Banjarmasin, Kalimantan Selatan
Latest Position Perawat Pelaksana

Date (DD/MM/YYYY) Start Date 1 Juni 2021 End Date 31 Juni 2021

Starting Salary Rp 1.750.000

Latest Salary

Reason for leaving Habis Masa Kontrak

May we contact this current/ previous employer directly?

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

Achievement(s)

Previous Company
RSUD Ulin Banjarmasin
Company Name
Jalan A. Yani Km. 2,5 No. 43, RW.05, Sungai Baru, Kec. Banjarmasin Tengah, Kota Banjarmasin,
Company Address
Kalimantan Selatan 70233
Latest Position
Perawat Pelaksana (Relawan Covid 19)

Date (DD/MM/YYYY) Start Date Februari 2022 End Date Mei 2022

Starting Salary Rp 3.000.000

Latest Salary

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 2

Starting Salary
Latest Salary

Reason for leaving Habis Masa Kontrak

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 3

Previous Company
Ciputra Mitra Hospital Banjarmasin
Company Name
Komplek Citra Land Jalan Ahmad Yani KM. 7,8 Manarap Lama, Pemurus Dalam, Kec. Kertak
Company Address
Hanyar, Kota Banjarmasin, Kalimantan Selatan 70654
Latest Position
Perawat Pelaksana

Date (DD/MM/YYYY) Start Date 14 Juli 2022 End Date 13 Juni 2024

Starting Salary Rp 2.400.000

Latest Salary

Reason for leaving Habis Masa Kontrak

May we contact this current/ previous employer directly?

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

Achievement(s)

ORGANIZATION STRUCTURE
1. Memelihara kebersihan ruang rawat dan lingkungannya.
2. Menerima pasien baru sesuai sesuai prosedur.
3. Memelihara peralatan keperawatan dan medis agar selalu dalam keadaan siap pakai.
4. Melakukan pengkajian keperawatan dan menentukan diagnose keperawatan sesuai batas kewenangannya.
5. Menyusun rencana keperawatan sesuai dengan kemampuannya.
6. Menyusun rencana keperawatan kepada pasien sesuai kebutuhan batas kemampuannya antara lain :
a. Melaksanakan tindakan pengobatan sesuai program pengobatan.
b. Memberi penyuluhan kesehatan kepada pasien dan keluarganya mengenai penyakitnya.
7. Melatih /membantu pasien untuk melakukan latihan gerak.
8. Melakukan tindakan darurat kepada pasien (antara lain panas tinggi, kolaps, pendarahan, keracunan, henti nafas dan henti jantung), sesuai dengan protap yang
berlaku selanjutnya segera melaporkan tindakan yang telah dilakukan kepada dokter ruang rawat/ dokter jaga.
9. Melaksanakan evaluasi tindakan keperawatan sesuai batas kemampuannya.

REFERENCES
List two person NOT related to you, who are familiar with your character, background or work performance (preferably your direct supervisor)
Name : Rini Astuti Contact No : 082251691049
Company : Job Position :

Years Known :
Relationship :

Name : Kameliandi Contact No : 082251691049

Company : Job Position :

Years Known :
Relationship :

CURRENT DETAILS OF SALARY AND BENEFITS

1. Monthly basic salary gross Rp2,400,000 IDR
2. Eligible for over time ? Tidak ( Yes / No )
If yes, monthly average ? Rp3,300,000
3. Allowances
Meal Rp15,000
Transportation Rp500,000 IDR
Phone/ Handphone - IDR
Others - IDR
4. Loan facilities Type of Loan Housing
Outstanding Amount - Max Limit -
Interest per Year - Outstanding Period - (months/ years)
Repayment Methods - (months/ years)

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 4

5. Annual Leave - (Days)
6. Annual Bonus :
THR (Festive Allowance) Rp2,400,000 IDR
Performance Bonus - IDR
Others, please explain - IDR

7. Medical Benefits Cashless Reimburstment

Out Patients (Per Year) 1,200,000 IDR
In Patients (Room & Board) kelas 3 IDR
8. Life Insurance - IDR
9. Other Benefits, Please Explain:
-

COMPENSATION BENEFIT EXPECTATION & COMMENCEMENT

1. Monthly salary (Gross) 3,715,000 IDR
2. Benefits / Others -
3. If you are offered employment with us
Agustus 2024
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)
Tidak

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)

Tidak

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)
Tidak

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)
If yes, When ? Tidak 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?
Tidak ada

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?
Tidak ada

7. Do you have any other job or business activities outside the current employment?
Tidak ada

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.

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 5

 Atika Nur Huda
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 6