APPLICATION FORM

CONFIDENTIAL
USE CAPITAL LETTERS

Position applied for : Photo 4x6

I. PERSONAL DATA

A. Personal Details
Full Name: Sex:
Place of Birth: Date of Birth: Religion:

Home Address & phone Identity Card No. Marital Status:

- Married
- Single
Hand phone : - Others

E-mail : Office phone:

B. Family Details
(Spouse and children)
Name M/F Age Education Job Company

Spouse

Child 1

Child 2

Child 3

C. Family Details
(Father, mother, brothers/sisters including you)
Name M/F Age Education Job Company

Father

Mother

Bro./Sis. 1

Bro./Sis. 2

Bro./Sis. 3

D. Health History
1. Have you had a rather severe illness/accident? Month/Year
If yes, please describe

2. Does it have a side effect presently ?

If yes, please describe

II. EDUCATION AND SKILLS

1
 A. Formal Education

Education School’s Name Major From / To GPA

High School

Academy

University

B. Non Formal Education : Course/Training/Seminar

Subject Provider Year/Period Paid by

1.

2.

3.

C. 1. Scientific publication including thesis

2. Extra curricular / Social / Teaching Activities

Name of Activities / Organization Position Year/Period

1.

2.

3.

D. Languages (fluent/slight)

Listening Speaking Writing

Fluent Fair Slight Fluent Fair Slight Fluent Fair Slight
1. English
2.
3.

E. Hobbies/sports

F. Scholarship/awards/prizes received :

III. WORK EXPERIENCE

(Four latest experiences, others please attach on separate page)

2
 Month Year Name/Address/Phone of Company Position

Fr.: First :

To Last :

Type of Business : Total Employees:

Name of Supervisor : Name of Director :

Major Tasks & Responsibilities

Major achievements

No. of employees supervised: Directly : Indirectly:

Major reason for change :

Minor reason for change:

Month Year Name/Address/Phone of Company Position

Fr.: First :

To Last :

Type of Business : Total Employees:

Name of Supervisor : Name of Director :

Major Tasks & Responsibilities

Major achievements

No. of employees supervised: Directly : Indirectly:

Major reason for change :

Minor reason for change:

Month Year Name/Address/Phone of Company Position

Fr.: First :

To Last :

3
 Type of Business : Total Employees:

Name of Supervisor : Name of Director :

Major Tasks & Responsibilities

Major achievements

No. of employees supervised: Directly : Indirectly:

Major reason for change :

Minor reason for change:

Month Year Name/Address/Phone of Company Position

Fr.: First :

To Last :

Type of Business : Total Employees:

Name of Supervisor : Name of Director :

Major Tasks & Responsibilities

Major achievements

No. of employees supervised: Directly : Indirectly:

Major reason for change :

Minor reason for change:

IV. SALARY & BENEFIT HISTORY

(Starting From Current / Latest Company)

1. Company Name : 2. Company Name :

Basic Net Salary : Basic Net Salary :

4
 Allowances (Transport, Meal, etc) : Allowances (Transport, Meal, etc) :

Bonus/Commision : Bonus/Commision :

Benefit (Medical, etc) : Benefit (Medical, etc) :

3. Company Name : 4. Company Name :

Basic Net Salary : Basic Net Salary :

Allowances (Transport, Meal, etc) : Allowances (Transport, Meal, etc) :

Bonus/Commision : Bonus/Commision :

Benefit (Medical, etc) : Benefit (Medical, etc) :

V. PROFESIONAL REFERENCES

1. Full Name : 2. Full Name :

Company : Company :

Address : Address :

Relationship : Relationship :

Phone : Phone :

VI. SALARY AND COMMENCEMENT OF EMPLOYMENT

1. Desired nett monthly salary?

2. Earliest date able to commence employment

I hereby declare that every statement given by me in this form is true, correct and given voluntarily. I authorize the
Management to submit the said information to any person or organization for the purpose of any investigation which the
Management may desire to make. I agree that if any false declaration is made by me, my agreement may be terminated
without notice.

Jakarta, 2018

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