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PT. AKR CORPORINDO TBK

Photo

APPLICATION FORM

Position to be applied : OPERATOR SAFETY ENGINEER (OSEG)

Full Name : KIKI GUNAWAN

Sex : M M/F

Place / Date of Birth : MEDAN, 28 JUNE 1989

Address : JLN. PELAJAR TIMUR GG. KELAPA LR. KENARI NO. 8A MEDAN - 20228

Phone (Home) : 0

Handphone : 0 8 5 7 6 1 4 8 3 2 6 0

Religion : MOSLEM

Marital Status : SINGLE

Tribe / Ethnic : JAVA

Identification number : 1 2 7 1 0 4 2 8 0 6 8 9 0 0 0 4
KTP / Passport / SIM

FAMILY

Place/Date of
Family Relation Name M/F Birth Education Occupation Position Company

Father SUDARMAN M MEDAN, 1954 SD Entepreneur

Mother ANIK BOINAH F P.RAJA, 1958 SD Housewife

A Older Brother 1. SUNINGSIH F MEDAN, 1979 SD Housewife

Sister 2. SUTRISNO M MEDAN, 1981 SD Entepreneur

3. DARMA SYAHPUTRA M MEDAN, 1984 SD Worker

4. HENDRA LESMANA M MEDAN, 1986 SMK Worker

5.

6.

B Younger 1. BOY MARWAN M MEDAN, 1994 SMA Student

Brother/Siste 2.

3.

4.

5.
6.
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FAMILY
Place/Date of
Family Relation Name M/F Birth Education Occupation Position Company
Husband / Wife
Daughter/Son 1.
2.
3.
4.
5.

EDUCATIONAL BACKGROUND

Education Level School's Name Place/City Major In Year Graduated Diploma GPA/IPK
Primary School MUHAMMADIYAH 17 MEDAN 2001
Junior High School SMP NEGERI 6 MEDAN 2004
Senior High School SMA NEGERI 5 MEDAN SCIENCE 2007
Academy / University POLITEKNIK NEGERI MEDAN MEDAN MECHANICAL ENG. 2012 III 3.39

INFORMAL EDUCATION

Course Name Organizer Period Diploma Sponsored by

1 PSYCHOLOGY MARSHAPUNTADEWA 2 DAYS YES POLITEKNIK NEGERI MEDAN
2 SEMI MILLITARY BRIMOB DAN POLMED 1 WEEK YES POLITEKNIK NEGERI MEDAN
3 INTERNATIONAL SEMINAUNIMED 1 DAY YES UNIMED
4 SEMINAR STC 1DAY YES ABCo, POLMED

Reading Writing Speaking

Foreign Language Good Fair Poor Good Fair Poor Good Fair Poor
1 ENGLISH Good Good Fair

2 JAVANESE Fair Fair Fair

Social Activities Place Title Period

1 FUITEN POLMED Politeknik Negeri Medan Leader of PHBI 2011-2012

2 HMPS POLMED Politeknik Negeri Medan Leader of Moslem Religion Section 2011-2012
3 HIRMAS Politeknik Negeri Medan Leader of PHBI 2007-2009

Hobby : Reading, sport, and music.

You're reading : A lot of Average A little

Topic : Sport, politic, job, and gadget.

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WORKING EXPERIENCE (Current Job & 1 Last Job)

1 Company's Name : PT. PLN Sektor Labuhan Angin Type of Business: Company's Annual Sales:

Date of Employment : Title:

Sub-ordinate :

Assignment & Responsibilities in your job :

Practical Training on the Field (PKL)

Current Basic Salary : Rp. __________ million net / gross

Benefits (please fill in for any one of them that you receive monthly besides your salary):
Meal Allowance : Rp. ________________ received per day
Transport Allowance : Rp. ____________ received per day
Gasoline Allowance : Rp. _____________ million received per month (if received in reimbursement amount, maximum amount Rp. ___________ million)
HP Allowance : Rp. _________________ received per month (if received in reimbursement amount, maximum amount Rp. ______________ )
Car Allowance : Rp. ________________ received per month
Do you get a company's car ? _____ YES _____ NO

If get company's car : Car Ownership Program (What type of car? _______________ ; Year of car manufactured? ____________ ; Years Remain? _______________

If get operational car : What type of car? ____________________ ; Year of car manufactured? _____________

Medical Coverage : ____________________________________________________________________________________________

Yearly Bonus Received : ____________________ ; Incentive Scheme : ________________________________________________

Please draw your position in the organization structure

Reason of Leaving :
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2 Company's Name : Type of Business: Company's Annual Sales:

Date of Employment : Title:

Sub-ordinate :

Assignment & Responsibilities in your job :

Current Basic Salary : Rp. __________ million net / gross

Benefits (please fill in for any one of them that you receive monthly besides your salary):

Meal Allowance : Rp. ________________ received per day

Transport Allowance : Rp. ____________ received per day

Gasoline Allowance : Rp. _____________ million received per month (if received in reimbursement amount, maximum amount Rp. ___________ million)

HP Allowance : Rp. _________________ received per month (if received in reimbursement amount, maximum amount Rp. ______________ )
Car Allowance : Rp. ________________ received per month

Do you get a company's car ? _____ YES _____ NO

If get company's car : Car Ownership Program (What type of car? _______________ ; Year of car manufactured? ____________ ; Years Remain? _______________

If get operational car : What type of car? ____________________ ; Year of car manufactured? _____________
Medical Coverage : ____________________________________________________________________________________________

Yearly Bonus Received : ____________________ ; Incentive Scheme : ________________________________________________

Reason of Leaving :
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REFERENCES

Name Contact Phone Number Title / Position Relation

Aulia Salman, S.T., M.T. 08163135427 Docent Docent

Ir. Burhanuddin Tarigan, M.T. 081361481260 Docent Docent

INFORMATION CONCERNING APPLICATION

No. Questions Yes No Explanations

1 Have you ever applied at our company before? NO

If Yes, when and what position did you apply for?

2 Are you engaged in a contract with the current working company? NO

3 Have you ever been hospitalized? NO

4 Do you smoke? NO

If Yes, how many cigarettes do you smoke a day?

5 Do you have a reference at PT. AKR Corporindo Tbk? NO

6 Have you ever been involved in a criminal case? NO

If Yes, what kind of criminal case?

7 Are you ready to be placed in other cities? If NO, please explain why? YES

8 Are you ready to be put on duty in other cities? If NO, please explain why? YES

9 What kind of job do you like? Operator, HRD, Logistic

10 What kind of job do you dislike? Sales

11 What kind of duty, knowledge or skill do you have? AutoCad, Ms. Office,Machinary and electricity.

12 What is your strong point? Planning, Organizing, and coordinating. I am also a hardworker.

13 What is your weakness point? Cannot be patient against people who disagree with me.

14 What kind of improvement can you offer to this company ? I will work hard and do all the best i can do to this company.

15 How much salary and what kind of benefits do you expect ? Rp. 2.500.000 , I am expecting on mess an old age insurance.

16 What date are you ready to begin the job? AS SOON AS POSSIBLE , I AM READY ANYTIME

I hereby declare that all of the above data and information are true and correct

Medan, 28 Oktober 2012

[ Kiki Gunawan ]