FUJI XEROX INTERNAL USE ONLY <<RESTRICTED>>

Disclose to : Hiring Manager/HR

Protected until : 7 years
Author : FXMSB HR
Prepared on : 1 Oct 2015
Document ID : 4110-201-D000002-06

APPLICATION FOR
EMPLOYMENT Strictly Private&Confidential

INSTRUCTIONS:

Theformmustbecompletedintheapplicants ownhandwriting.
Copies
ofcertificatesandtestimonialsshouldbeattachedtotheapplicationforms.Theoriginalsshouldbeattachedto Attachpassportsized
theapplicationforms.Theoriginalsshouldbeproducedwhencalledforinterview. photographhere
Refereesshouldnotberelativesormembersoftheapplicantsfamily.Ifpossible,
atleastoneoftherefereesshouldbecompetenttogiveanassessmentofhis/heracademiclife.
Ifspaceonthisformisinsufficient,please attachasaddendum.

POSITIONAPPLIEDFOR : _ _ ___ ___

Howdid youcometoknowofthis vacancy?

Jobstreet CareerFair Employment Agency Referralby Friends/Relatives Others(pleasespecify:__

)Haveyou previouslyemployedbyFuji Xerox?If yespleaseindidate

Co:_ _ Lastposition held:__ _ Period:From __ To_

Reason(s)forleaving:_ _ __

PERSONALINFORMATION

FULLNAME(inBLOCKLETTERS,asstatedonyourIdentityCard/BirthCertificate)

NRICNo/Passport(New) DateOfBirth Citizenship

- -
Day Month Year

PLACEOFBIRTH(TOWN/STATE) Sex Age Driving LicenceNo CarType

M /F Car/Motocycle

Pleasetick()andspecifywhereapplicable

Race [ ] Malay [ ] Chinese [ ]Indian [ ] Others _ _

Religion [ ] Islam [ ] Buddhist [ ]Hindu [ ] Christian [ ]Others_ _
Maritalstatus [ ]Single [ ] Married [ ]Widowed [ ] Divorced

Current/PostalAddress

City State Postcode/Zip

Contact
(H) (H/P) - (O)

Email
 FAMILYPARTICULARS

SPOUSEPARTICULARS(Ifmarried)
Fullname Spousesemployer/CompanyName
_ _ _ _

Spousesemployer/CompanyAddress
_ _ _ _ _
Occupation Citizenship
_ _ _ _ _
_ _ _ _

CHILDREN(Ifany)

FullName Age Sex School/CompanyNameandAddress Occupation(Ifemployed)

PARENTS
Fathersname:Jo Mothersname:Jo
btitle:Employers btitle:Employers
name: name:

SIBLINGS(Ifany)
FullName Age Sex School/CompanyName Occupation(Ifemployed)

NEXTOF KIN(For contactin case ofemergency)

Fullnameofperson Relationship Address&ContactNumber

LANGUAGEAND DIALECTPROFICIENCY
LANGUAGE/DIALECT SPEAK WRITTEN
Pleasetick()whereapplicable Fluent Fair Poor Fluent Fair Poor
English
BahasaMalaysia
Mandarin
Others(pleasestate,ifany):

COMPUTERLITERACY
PLEASESTATETHERELEVANTTYPE OFPROGRAMMES/SOFTWAREAPPLICATIONSTHATYOUARESKILLED AT
 EDUCATION INFORMATION

NameOfSchool/College/ Certificate/Diploma/Degree/ YearAttained

University ProfessionalQualificationAttained From To

EMPLOYMENT HISTORY

Present Employment

Employer Fromyear/month Toyear/month

AddressTelep NatureofEmployerBusiness

honeNo Name&PositionofSuperior

Positionsheldincompany Duration MajorResponsibilities

Salary Bonus Commission OtherBenefits/Allowances

(Months)
Starting(RM)
Current(RM)
Describethedutiesandresponsibil itiesofyourpresentposition BasicSalary
Date
DutiesandResponsibilities PercentageTimeSpent ReasonForLeavi
NameofEmployer LastPositionHeld Starting Last Drawn
From To RM RM
ng

Reasonsforleaving

DETAILSOFPREVIOUSEMPLOYMENT
(Pleasefillupthefollowinginchronologicalorder,fromyourfirstemploymenttothemostup-to-date/current)
Date NameofEmployer LastPositionHeld BasicSalary ReasonForLeavi
PLEASETICK()(ANDSPECIFY) WHEREAPPLICABLE:
1.Haveyoubeen/areyousufferingfromanyphysicalimpairmentordisease/illness
[ ] Yes [ ] No
eg.Diabetes,Epilepsy,HighBloodPressure,stammering&etc?

2.Haveyouhadsurgeryofanykindbefore?Ifso,pleasespecifywhattypeandwhen:
[ ] Yes [ ] No
_ _ _ _ _

3.Haveyouever beenchargedwith or beenconvictedofacriminaloffenseinaCourtOfLawin

[ ] Yes [ ] No
anycountry?If yes,pleasestatethedate anddetailsoftheoffence/s:

Date ofoffense _ _ _ _
_Detailsofoffense _ _ _ _
_
4.Areyouabankrupt/facingbankruptcy? [ ] Yes [ ] No

5.Doyouhave anyrelativesorfriendsworkingfor thisCompany?(Pleasetick()where

applicable)Ifyes,pleasestatethe [ ] Yes [ ] No

Nameof friend/relative __ _ _ _
Relationship _ _
_ Position intheCompany
_ _ _ ____________Name ofCompany
_ _ _ Location
_ _ _
6.Haveyoueverbeendismissedorsuspendedfromanypositionbyyourpast/presentemployers? [ ] Yes [ ] No
Ifso,pleasestatereason/sfordismissal/suspension:

_ _ _ _

7.Are youflexiblewithyourschedule?(i.e,willingtoworkshiftworkinghours) [ ] Yes [ ] No

8.Forfemaleapplicantsonly:Areyoupregnant? [ ] Yes [ ] No

CHARACTERREFERENCES

Nametwo(2)peoplethattheCompanymaycontactforcharacterreferences,excludingfamily/relatives, one of them must be your superior in the past/current

employment:

Relationship( Years Contact

FullNameOfReferees Company JobTitle
WithApplicant) Known Number

I give or do not give permission to take up my reference prior to an offer of employment being made.

ExpectedSalary:RM _ _ NoticePeriod :__ Month(s)

 DECLARATION BY THE APPLICANT
DECLARATION BYTHEAPPLICANT

Data Protection Statement

The information that you provide on this form and that obtained from other relevant sources will be used to process
your application for employment. Thepersonal information that you give us will also be used in a confidential
manner to help us monitor our recruitment process. If you succeed in your application and take up employment
with us, the information will be used in the administration of your employment. We may also use the information if
there is a complaint or legal challenge relevant to this recruitment process. We may check the information
collected. We may also use or pass to certain third parties information to prevent or detect crime, to protect public
funds, or in other ways as permitted by law. By signing the application form we will be assuming that you agree to
the processing of sensitive personal data, in accordance with our registration with the Data Protection
Commissioner.

Declaration

I declare that the information I have given in this application is accurate and true. I understand that providing
misleading or false information will disqualify me from appointment OR, if appointed, may result in my dismissal and
possible referral to the police. I have not willfully suppressed any material act.

Name :________________________________

Signature :________________________________

Date :________________________________