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APPLICATION FORM
(Write in Capital Letters)
Position Applied For EXPECTED SALARY Available Starting Date
A. PERSONAL INFORMATION
PERSONAL DATA
Full name : Male Female
Place / Date of birth :
Address :
City : Post code :
Telephone (residence) : Telephone (office) :
Hand Phone :
E-mail Address :
I.D. Card Number : Date of Expiry :
Religion : Height / Weight :
FAMILY RECORD
Marital Status : ________________________ Number of Children : ______________________
Husband/Wife Name : ________________________ Age _______ Occupation __________________
Children Name : 1. _________________________________________ Age _________ M/F
2. _________________________________________ Age _________ M/F
3. _________________________________________ Age _________ M/F
Father Name ________________________ Age _______ Occupation __________________
Mother Name ________________________ Age _______ Occupation __________________
Contact person in case of emergencies _____________________________ Phone. _____________________
B. EDUCATION
Name and address of school, university From To Degree or
Major Course or Study
or other Training Institutions. (MM/YY) (MM/YY) Certificate
C. RECORD OF PREVIOUS EMPLOYMENT
1. Company Name : ___________________________________ Telephone : _________________
Address : ___________________________________ Position : _________________
Nature of business : ___________________________________ Salary : _________________
Employment dates : from ____________ to ____________ Supervisor’s Name : __________________
Duties : _____________________________________________________________________
Reason for leaving : _____________________________________________________________________
2. Company Name : ___________________________________ Telephone : _________________
Address : ___________________________________ Position : _________________
Nature of business : ___________________________________ Salary : _________________
Employment dates : from ____________ to ____________ Supervisor’s Name : __________________
Duties : _____________________________________________________________________
Reason for leaving : _____________________________________________________________________
3. Company Name : ___________________________________ Telephone : _________________
Address : ___________________________________ Position : _________________
Nature of business : ___________________________________ Salary : _________________
Employment dates : from ____________ to ____________ Supervisor’s Name : __________________
Duties : _____________________________________________________________________
Reason for leaving : _____________________________________________________________________
4. Company Name : ___________________________________ Telephone : _________________
Address : ___________________________________ Position : _________________
Nature of business : ___________________________________ Salary : _________________
Employment dates : from ____________ to ____________ Supervisor’s Name : __________________
Duties : _____________________________________________________________________
Reason for leaving : _____________________________________________________________________
REFERENCES (Non – Relatives)
1. Name : ______________________ Phone/Mobile: _________________ Company : _______________
E-Mail : _______________________________________________ Years Known : _______________
2. Name : ______________________ Phone/Mobile: _________________ Company : _______________
E-Mail : _______________________________________________ Years Known : _______________
3. Name : ______________________ Phone/Mobile: _________________ Company : _______________
E-Mail : _______________________________________________ Years Known : _______________
OTHER ACTIVITIES
Name of Organization From date To date Status
Excellent Good Average Not Good
Language Proficiency
English
Mandarin
Other _______________________
Computer
Word
Excel
Other ________________________
Serious Illness
Lungs Veneral Disease Heart Hypertension
Ayan Diabetes Cancer Other_____________
The Positive in Yourself
STRENGTH WEAKNESS
I certify that all statements made on this application are true and complete to the best of my knowledge.
I understand that misrepresentation or omission when discovered, will subject me to discharge and I hereby
authorize any investigation relating to my work experience, education, or reputation for the purpose of my
application for employment.
Signature,
__________________
D. INTERVIEW SHEET
CODE : 1. Poor 2. Average 3. Good 4. Excellent
Interviewer’s by HRD HOD GM
Name / Date of Interview
OBSERVATION
APPEARANCE
PERSONALITY
INITIATIVE LEADER ABILITY
COMMUNICATION SKILL
MOTIVATION
STABILITY
TECHNICAL SKILL
CO-OPERATIVE ATTITUDE
EXPERIENCE BACKGROUND
Overall Comment
ACCEPTED/NOT ACCEPTED
For Human Resources Department Only
REFERENCE CHECKING
1. Name / Company : _________________________________ Date : _______ Comment : _______________
2. Name / Company : _________________________________ Date : _______ Comment : _______________
3. Name / Company : _________________________________ Date : _______ Comment : _____________
Recommended ( ) Yes ( ) No Site Inspection ( ) Yes ( ) No
Hired ( ) Yes ( ) No Put on Hold ( ) Yes ( ) No
APPROVED FOR HIRE
Position : __________________________________
Starting Date : __________________________________
Level : __________________________________
Basic Salary : Rp. _______________________________
Service Charge : Rp. _______________________________
Others Benefit : Rp. _______________________________
Gross Salary : Rp. _______________________________
Approved by, General Manager __________________________________ Date : _____________
