APPLICATION FORM

No. QR/HNRD/PRS/03.Rev.00

page 1 of 5

CONFIDENTIAL
1. This form should be answered written in block capital letters by the applicant.
2. If any information given is not true, the company has the right to cancel or terminate the work
relationship or as demanded in law procedure.
3. * Cross where not appropriate.
Job Applied :

A. PERSONAL DATA
Full Name

Place/Birthdate

Hobbies

Religion

Ethnic
Group

Formal Education

Title

Issued in

KTP No

Telp. No./E-mail

Address

Male/Female *

B. FAMILY
1.

Marital Status

2.

Members of family ( Husband/Wife and Children )

If they have passed away, please mention their last education & job.
How many children do you have? _______
Family
Spouse
Child 1
Child 2
Child 3

Single
Engaged

Name

Married
Divorced

M/F

Birthdate

Education

Job

APPLICATION FORM
No. QR/HNRD/PRS/03.Rev.00

page 2 of 5

CONFIDENTIAL
3.

Do you have other dependents besides your wife or children ?

4.

House Status
Private owned
Rent

5.

Parent Owned
Contract

Relative owned
Other .....................

Parents family (including applicant)

If they have passed away, please mention their last education & job.
Applicant is the ________ child of __________ children.
Family

Name

M/F

Father

Mother

Birthdate

Education

Job

Child 1
Child 2
Child 3

C. EDUCATION
1.

Formal Education (begin from Senior High School)

no

Institution Name

Major

Place

a.

From
19___

To
19___

b.
c.
2.

Have you ever failed in school ?______________How many times ?______________

Why?____________________________________________________________________________

3.

Did you ever get any achievements in any field? If yes, please describe briefly.

4.

Do you posses any computer skills? If yes, please describe briefly.

5.

Courses Attended

APPLICATION FORM
No. QR/HNRD/PRS/03.Rev.00

page 3 of 5

CONFIDENTIAL
no

Topic Of Course

Organizer

Period

a.
b.
c.
6.

D.
1.

Foreign Language
a.

Speak

Read

Write

b.

Speak

Read

Write

WORKING EXPERIENCE (please mention the last 3 company)

Name of Company
Line of Business
Period of work (month-year)

up to

The last position

The job description
Last nett salary
Reason for leaving

2.

Name of Company
Line of Business
Period of work (month-year)
The last position
The job description
Last nett salary
Reason for leaving

up to

APPLICATION FORM
No. QR/HNRD/PRS/03.Rev.00

page 4 of 5

CONFIDENTIAL
3.

Name of Company
Line of Business
Period of work
(month-year)

up to

The last position

The job description
Last nett salary
Reason for leaving

E.

REFERENCES
Name your references (not less than two, not in this company, nor your friend or family)
no

Name

Position

Relationship

Telp No.

1.
2.

F. INTEREST AND PERSONAL CONCEPT

1.

Please indicate by number, your choice of job type, according to your preference.
Kinds of job
Accounting
Engineering
Finance
General Affair
Marketing/Sales

No.

Kinds of job
Personnel
Production/Manufacturing
Research
Service/Maintenance
Other____________________

2.

Why do you choose the first 2 numbers in the above?

3.

The working environment you prefer :

Office

Factory

Laboratory

No.

Field

Why?
4.

Why do you want to join this Company?

5.

What do you know about this Company

6.

Do you have any objection to work overtime, to be stationed anywhere deemed necessary by the

APPLICATION FORM
No. QR/HNRD/PRS/03.Rev.00

page 5 of 5

CONFIDENTIAL
Company?
7.

When will you be able to start working?

8.

What is your expected salary?

9.

What kind of Fringe benefits (facilities) do you desired?

10.

Name the person (s) or your relative (s) in our company

11.

Did you ever do the Psychological test (IQ, Aptitude, Personality test) ? If yes, please mention
where, when and for what purpose?.

12.

Did you ever involve in criminal cases? If yes, please describe the case, sanction, where and when!

13.

Social Activities
no

Name of Organization

a.
b.
c.

Hereby, I certify that the above statements are true and correct.
Jakarta, ............................................

( ____________________________ )

Period

Position