Referral Information Form

Name of Applicant : Firmansyah Akbar

Position Applied : Land Representative

1. Do you have any relatives in Chevron?

□ No
□ Yes
2. If yes, what is the relation with you?
□ Husband/Wife □ Grandparents
□ Children □ Uncle/Aunt
□ Brother/Sister □ Parents in Law
□ Parents □ Other, please specify: _________________
3. Name of your Chevron Relative : Ir. H. Zulkarnain Warga Dalam__________________________
4. Position of your Chevron Relative (if known) : -__________________________________________________
5. Email of your Chevron Relative (if known) : -__________________________________________________

6. Are you a current or former government employee?

□ No
□ Yes
7. Are you a current or former employee of a company owned by the government?
□ No

□ Yes

8. Do you have any close family working in Government/State Owned Company/Political Party Member? Refer to Note A
& B below.
□ No
□ Yes
9. Do you have any close family which is former Government /State Owned Company/Political Party Member? Refer to
Note A & B below.
□ No
□ Yes

10. If yes, what is the relation with you?

□ Husband/Wife □ Grandparents
□ Children □ Uncle/Aunt
□ Brother/Sister □ Parents in Law
□ Parents □ Other, please specify:
11. If yes, please fill below information:
□ Name of your Relative : __________________________________________________
□ Position of your Relative : __________________________________________________
□ Name of Government Institution/State Owned Company/ Political Party:
__________________________________________________

Note:
A. Definition of Close Relatives: means any child, grandchild, parent, grandparent, spouse, sibling, in laws, nephew/niece. The
definition includes adoptive relationships as well as those acquired through marriage for all the parties listed in the definition
B. Definition of Government Officials: Active or Former or Close Relatives of the following:

 Any officer, employee or other person of a non-U.S. government, or department of agency thereof
 Any individual or employee of an entity owned or controlled by a non-US government (instrumentality)
 Any officer, employees or other person acting in an official capacity of a public international organization formed by 2 or
more governments
 Any individual of an organization operating with official government-like authority (and yet may not be paid by the
government)
 Any political party or officials, or candidate for non-U.S. political office or
 Any official’s close relatives or associates (e.g. mothers, fathers, brothers, sisters, spouses, children, grandparents,
parents in law)
 This may include traditional rulers, tribal leaders or informal advisors to the government.