APPLICATION FORM
CONFIDENTIAL
USE CAPITAL LETTERS
Position applied for :
I.
Photo 4x6
PERSONAL DATA
A. Personal Details
Full Name:
Place of Birth:
Sex:
Religion:
Date of Birth:
Home Address & phone
Identity Card No.
Marital Status:
- Married
- Single
- Others
Hand phone :
E-mail :
Office phone:
B. Family Details
(Spouse and children)
Name
M/F
Age
Education
Job
Company
C. Family Details
(Father, mother, brothers/sisters including you)
Name
M/F
Age
Education
Job
Company
Spouse
Child 1
Child 2
Child 3
Father
Mother
Bro./Sis. 1
Bro./Sis. 2
Bro./Sis. 3
D. Health History
1. Have you had a rather severe illness/accident?
If yes, please describe
Month/Year
2. Does it have a side effect presently ?
If yes, please describe
II. EDUCATION AND SKILLS
1
A. Formal Education
Education
High School
Schools Name
Major
From / To
GPA
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)
Fluent
Listening
Fair
Slight
Fluent
Speaking
Fair Slight
Fluent
Writing
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)
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 :
Type of Business :
Total Employees:
3
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 :
Allowances (Transport, Meal, etc) :
Allowances (Transport, Meal, etc) :
Bonus/Commision :
Bonus/Commision :
4
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.
2.
Desired nett monthly salary?
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,
2016
For official use only:
Remarks by Director of Human Resources:
Signature:
Date:
Remarks by Department Head:
Signature:
Date:
Selected Candidate (For HR Department)
Position: ______________________________________ Headcount:
_____________________________
Start Date: ____________________________________ Level:
__________________________________
Contract / Permanent: _________________________ Report to:
_______________________________
Other Comments :
