CONFIDENTIAL

PT PELAYARAN TEMPURAN EMAS Tbk

& Subsidiaries

EMPLOYMENT APPLICATION FORM

NAME : …………………………………………………… PHOTO

APPLIED POSITION : …………………………………………………… (ATTACH HERE)

FILL OUT THIS FORM WITH CAPITAL LETTERS

JOB VACANCY INFORMATION SOURCE

Career Day Internet : …………………. Relation
Advertisement Friend Others ………………………….

PERSONAL INFORMATION
Full Name : …………………………………………………………. Male Female

Birthplace : …………………………………. Date Month Year

Present Address : Citizenship : …………………………………………......

………………….……………………………………………. Home Phone : ……………………………………………..

………………….……………………………………………. Mobile Phone : ..……………………………………………

City : ………………………..…. ZIP : …….……… Email : ……………………………………………..

ID Card / Passport Number : Residence Ownership Status :

…………………………………………..
Personal Family Rent Others ………………...
Driving License Number :
…………………………………………..

Taxpayer Identification Number :

…………………………………………...

Religion : Muslim / Catholic / Christian / Hindu / Buddhist / Others…………………………………………………

Blood Type : A B AB O Weight : /kg Height : /cm

F/HRD-R&S/02 rev.00 – [1]

 Parents / Family Address : Citizenship : ……...……………………………………….

……………………………………………………………….. Home Phone : .…………………………………………….

.
……………………………………………………………….. Mobile Phone : ………………………………………………

City : ………………………..…. ZIP : …….………

Own a Vehicle : Yes No Vehicle Ownership Status:

Personal Family Company Others ………………

Type / Model : Year :

FAMILY
Marriage Status Single Married Others ………………………………….

Relationship Name Date of Birth Latest Education Occupation

Father

Mother

Siblings 1.
(include yourself) 2.

3.

4.

5.

Spouse

Child 1.

2.

3.

Dependents (Please state – Total, Relationship and Age) :

………………………………………………………………………………………………………………………………..

If there is an emergency situation, person we can contact (Please state – Name, Relationship, and Telephone Number) :

Name : ........................................ Relationship :............................. Telephone Number : ..................................

EDUCATION
Graduation
Education Institution Name Location Department GPA
Year

High School

Diploma/Academy

Bachelor

Master/Doctorate

F/HRD-R&S/02 rev.00 – [2]

LANGUAGE ABILITIES
Verbal Writing
Foreign Language
Poor Average Good Excellent Poor Average Good Excellent
1.

2.

REFERENCES (except family)

Name Company Position Telephone How Long Know You in What
Number capacity
1.

2.

WORK EXPERIENCE (fill out from the latest job)

  
Company Name

Address

Telephone Number

Business Field

Entry Position

Period (From - To)

Number of Subordinate

Last Position

Period (From - To)

Number of Subordinate

Job Desc (Last Position)

Immediate Supervisor

Reason of Resignation

F/HRD-R&S/02 rev.00 – [3]

 Draw your latest position at your company’s organization structure

Working Achievement

1.

2.

3.

OTHERS
Please state and explain the kind of job which fit into your career plan
…………………………………………………………………………………………………………………………………………....
Please state and explain the kind of job you don’t like and feel reluctant to do
……………………………………………………………………………………………………………………………………………

Are you willing to undergo these things?

1. Psychology Test Yes No

2. Probation Period Yes No
3. Business Trip to Other Cities Yes No
4. Placed at Different Location Yes No

Please answer these questions :

Do you have a side job? If yes, state the name of your company and position Yes No
……………………………………………..

Do you have relatives who work in our company? If yes, please state their name Yes No
and relationship with you..…………………….........................

Have you ever / currently suffered severe illness or accident that makes you Yes No
hospitalized? If yes, please state ……………………………………

Is it okay if we ask for reference from your previous company? Yes No

If you are accepted, when can you start working? ………………………….…………………….

I hereby declare that all the given information above is true. If I falsify information, I’m ready to accept all the consequences,
and Management have a right to terminate my employment or doing other necessary course of action. If I’m accepted, I
agree to abide by the rules and regulations of PT. Pelayaran Tempuran Emas, Tbk.

City Signature

Date Month Year Full Name

F/HRD-R&S/02 rev.00 – [4]

PT PELAYARAN TEMPURAN EMAS Tbk
& Subsidiaries
SALARY INFORMATION FORM

Name :…………………………………….

Applied Position :…………………………………….

Salary in Previous / Current Company Expected Salary

F/HRD-R&S/02 rev.00 – [5]