FRM-HR-002/Rev.

00

PT. KEMIKO INDONESIA

JOB APPLICATION FORM

No :

I. PERSONAL DATA
Full Name
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Address Postal Code

Phone I Mobile
Place I Date of Birth : Email Address :
Religion
Marital Status
ID Licence Number Expire Date:
/Driving
II. EDUCATIONAL HISTORY
Level of Education Name of School Major City Graduation Year
Elementary School
Junior High School
Senior High School
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Bachelor (Academy/University)
Post Graduate (Academy/Univ)
III. COURSE I SEMINAR I TRAINING
Course(s) Taken Institution Year I Duration

IV. ADDITIONAL INFORMATION OF EDUCATION

1. Achievements during school/college/university years (class
a) , year
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b) , year

2. Who financed your education ?

3. Title of scientific paper (thesis, articles, books, etc) :

V. ACTI VITIES
1. Membership in organization I institution
Name of Organization Location Position Period
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2. Interested newspaper I magazines : Newsweek,Asiaweek,Local Newspaper (Inquirer,Manila Bulletin)

Interesled topic.s : Business,Politics,Success stories of Prominent Individua ls
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VI. EMPLOYMENT HISTORY (2 last companies)

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No Company Addres & Phone Number Posi Duration Remmuneration Package

tion
1 Salary:
Transport:
Meals:
Vehicle:
Medical:
2 Salary:
Transport:
Meals:
Vehicle:
Medical:
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3 Organizational Structure Which Describes Your Position In The Last Company

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4 Job Description (In The Last Company)

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5 Other languages Speaking Writing Reading

Good Fair Less Good Fair Less Good Fair Less

Mark with (x) symbol at your chosen column

.
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6. Reasons for leaving the last company

Choose one I some & explain the reasons briefly :
6.1. Remmuneration problem : ……………………………………………………………………………
6.2. Relationship with the superior : ……………………………………………………………………………
6.3. Management of the company : ……………………………………………………………………………
6.4. Family problem : …………………………………………………………………………...
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6.5. Career plan : ……………………………………………………………………………

6.6.Other disappointments : ……………………………………………………………………………

7. Achievements which have been accomplished during work:

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VII. FAMILY
1. Residential status a) own b)rent c)family
2. Birth Order: 1st/2nd/... •) child From .......... siblings
Parents Name Age Education Employement
Father
Mother
Addres
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Brother (s) / Sister (s)

1
2
3
4
5
6
Spouse
Children
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1
2
3
4
Father in Law
Mother in Law
Address
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VIII. OTHER THINGS RELATED WITH JOB APPLICATION

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L Reasons I Objective to apply :

2. interested job environment :
IX. a. Office b. Laboratorium c. Field d. .............
3. Position applied : MI
4. a. Interested minimum salary (all inclusive, Nett) : SC
b. Other facilities :a. Car EL
b. Transportation Service LA
c. Medical NE
d. Others... OU
5. Are you willing to : S
a. Have 3 months probation : (Y/N)
b. Travel for official duty : (YIN)
c. Be placed out of town : (Y/N)
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1. Have you suffered from serious illness ? Illness :

Year :
2. Have you experienced serious accident ?
Accident : Year :

Consequence :
3. Blood Type
4. Type of vehicle that you use :
Belongs to
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5. Familiar employee at this company :

Explain the relationship with them ?

6. Write down 2 names of your contacts in this company (if any)

Name Address Phone Number

7. Write down 2 names of your relation who can give references about your application.
Name Address Phone Number
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8. Availability : If you were accepted, when will you be ready to work

I declare that all information given from this job application form is correct and true.
I will be held accountable in any consequences if in the future the information given above is found out to be in-
correct/un-true.

Date,
,
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