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Application Form

This document contains a personal data form with sections for: 1. Personal information including name, address, ID details, marital status, etc. 2. Formal education history from primary school to post-graduate programs. 3. Informal education, language proficiency, organizational activities, family, job experience, references, health records, and a statement of accuracy from the applicant.

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Ikhsan Fauzi Gp
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31 views5 pages

Application Form

This document contains a personal data form with sections for: 1. Personal information including name, address, ID details, marital status, etc. 2. Formal education history from primary school to post-graduate programs. 3. Informal education, language proficiency, organizational activities, family, job experience, references, health records, and a statement of accuracy from the applicant.

Uploaded by

Ikhsan Fauzi Gp
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
Download as pdf or txt
Download as pdf or txt
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PHOTO

PERSONAL DATA
Job applied (according to priorities): 1. 2.

Full name Nickname

Home Address Phone No.

Address (as in ID) Mobile Phone No.

Place and date of birth Gender


Male
Female
ID Card No. License A/B/C Religion

Height Weight Citizenship

Marital Status Vehicles used


Married Public vehicles
Single, plan to get married on _________________________ Private vehicles
Widow Company vehicles
Email Address
Type/brand/year ______________________________

FORMAL EDUCATION
YEAR
LEVEL SCHOOL NAME PLACE MAJOR
FROM TO GRADUATE/NOT GPA
PRIMARY
SECONDARY
HIGH SCHOOL
DIPLOMA
BACHELOR
POST GRADUATE

INFORMAL EDUCATION
YEAR
FIELD / TYPE ORGANIZER CITY LONG COURSES
FROM TO GRADUATE/NOT

LANGUAGE PROFICIENCY (filled with: POOR/ MODERATE/ GOOD/ EXCELLENT)


LANGUAGE LISTENING READING SPEAKING WRITING
ORGANIZATION ACTIVITIES
YEAR
ORGANIZATION ACTIVITIES POSITION
FROM UNTIL

FAMILY ARRANGEMENT (including yourself)


LAST JOB
RELATIONSHIP NAME M/F AGE LAST EDUCATION
POSITION COMPANY REMARKS
FATHER
MOTHER
SIBLINGS 1
SIBLINGS 2
SIBLINGS 3
SIBLINGS 4
SIBLINGS 5

Filled if already married


SPOUSE
CHILD 1
CHILD 2
CHILD 3

JOB EXPERIENCES (filled from the last experiences)


NAME & COMPANY ADDRESS
PERIODE
LAST POSITION
RESPONSIBILITIES
REASON OF RESIGNATION
NAME OF SUPERIOR & POSITION

NAME & COMPANY ADDRESS


PERIODE
LAST POSITION
RESPONSIBILITIES
REASON OF RESIGNATION
NAME OF SUPERIOR & POSITION

NAME & COMPANY ADDRESS


PERIODE
LAST POSITION
RESPONSIBILITIES
REASON OF RESIGNATION
NAME OF SUPERIOR & POSITION

JOB REFERENCE (whom can be contacted about you: 1. Ex boss ; 2. Ex colleague; 3. Ex partner)
NAME COMPANY POSITION PHONE NO. RELATIONSHIP
ORGANIZATION STRUCTURE (draw the organization structure of your position in your last office)

EMERGENCY (person to be contacted in terms of emergency)


NAME ADDRESS PHONE NO. RELATIONSHIP

HEALTH RECORD
Have you been/ are suffering chronic pain/ heavy accident/ surgery?
When and what kind? Explain.
Never
Ever/ yes, explanation
_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Do you have
1. Asthma Yes No
2. Hepatitis Yes No
3. TBC Yes No
4. Heart disease Yes No
5. Diabetics Yes No
6. Epilepsy Yes No

7. Allergy
Yes, allergy to ________________________________________________
No

8. Other disease that have not been mentioned?

_______________________________________________________________________

Have you ever suffered broken bones? No Yes, in year _______ in part __________
Do you smoke? No Yes, approximately _________________/ day
Are you alcoholic? No Yes, kind of drink __________________
Do you use drugs? No Yes, in year _______________________

Do you have problems with your five senses?


1. Eyes Normal Minus Plus
2. Color-blind Yes No
3. Smell Problems No
4. Hearing Problems No
5. Taste Problems No
OTHERS
Mention the strength of yourself: Mention the weakness of yourself:
1. 1.

2. 2.

3. 3.

ANSWER
QUESTION
YES NO EXPLANATION
Do you have friends/ family working in this group/
company? (Super Indo, Indo Maret, Indo Grosir, Intraco). If
yes, mention the name, position, company and the
relationship with you.

Have you ever been dealing with police because of crimes?

Are you willing to be assigned/ placed outside Jakarta/


outside the island?

Are you willing to work on Saturday/ Sunday/ holiday?

Are you willing to work shift?

Do you have a plan to get married/ pregnant (for women


only)? When?

When can you start to work in this company?

STATEMENT
I hereby declare that the information provided above is correct. When there is injustice, then I am fully responsible for the consequences, and willing
to be penalized with company regulations.

I attach copies of supporting documents

_________________, ______/_______/________

_________________________________________
Signature and name

NOTE (filled by the interviewer)

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