APPLICATION FORM

POSISI YANG DILAMAR / POSITION APPLIED

INFORMASI PELAMAR / APPLICANT INFORMATION

Nama Lengkap / Full Name Nama Panggilan / Nick Name
Tempat Lahir / Place of Birth Tanggal Lahir / Date of Birth
Agama / Religion Sex Status / Marrital Status
Nama Suami/Istri / Spouse Name Nama Ibu / Mother's Name
Warganegara / Citizenship Indonesia Suku / Ethnic Foreigner Country
No. Identitas / ID No. NPWP No.
SIM / Driving Licence Type A C Lain / Other No.
BPJS No. Tenaga Kerja / Labor Kesehatan / Health
Rekening Bank Bank Account No. Nama / Name
Alamat 1 / Address 1
Sesuai KTP / as shown on ID

Alamat 2 / Address 2

Phone No.
Email
Dalam kondisi darurat, tolong hubungi / In case of emergency, please contact :
Nama / Name
Alamat / Address

Phone No.
Hubungan / Relation Status
PENDIDIKAN FORMAL / FORMAL EDUCATION
SMU / High School Alamat / Address
Tahun / Year s/d / until Lulus / Passed ? Y N
Universitas / University Alamat / Address
Tahun / Year s/d / until Lulus / Passed ? Y N
PENDIDIKAN NON FORMAL / NON FORMAL EDUCATION / TRAINING
SUBYEK / SUBJECT BLN/THN MONTH/YEAR KETERANGAN / REMARKS

KETRAMPILAN / SKILLS
SKILL DESKRIPSI / DESCRIPTION A B C Contreng (√) kolom yang sesuai
1 Thick (√) the appropriate section
Bahasa / Language 2
3 Note :
1 A - Sangat Bagus / Very Good
Computer 2 B - Bagus / Good
3 C - Cukup / Fair
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REFERENSI / REFERENCES
Sebutkan 3 (tiga) referensi profesional / Mentioned 3 (three) professional references
Nama / Name Hubungan / Relation Status
Perusahaan / Company Phone No.
Alamat / Address

Nama / Name Hubungan / Relation Status

Perusahaan / Company Phone No.
Alamat / Address

Nama / Name Hubungan / Relation Status

Perusahaan / Company Phone No.
Alamat / Address
PENGALAMAN KERJA / WORKING EXPERIENCES

Perusahaan / Company
Alamat / Address
Phone No.
Jabatan / Position
Spv/Mgr Name
Deskripsi Pekerjaan
Job Description

Gaji awal / First Salary Gaji Akhir / Last Salary

Working Period Year until Year
Reason of Leaving
Dapatkah kami menghubungi supervisor / manager di perusahaan tersebut, untuk referensi? Y N
Can we contact your previous supervisor / manager in that company, for reference?

Perusahaan / Company
Alamat / Address
Phone No.
Jabatan / Position
Spv/Mgr Name
Deskripsi Pekerjaan
Job Description

Gaji awal / First Salary Gaji Akhir / Last Salary

Working Period Year until Year
Reason of Leaving
Dapatkah kami menghubungi supervisor / manager di perusahaan tersebut, untuk referensi? Y N
Can we contact your previous supervisor / manager in that company, for reference?
 APPLICATION FORM

LATAR BELAKANG KELUARGA/ FAMILIY BACKGROUND

Status Hubungan / Usia / Pekerjaan / Nama Perusahaan / Nomor Telpon / Phone
Nama / Name
Relation Status Ages Profession Company Name Number
Ayah /Father
Ibu /Mother
Saudara / Brother or
Sister
Saudara / Brother or
Sister
Saudara / Brother or
Sister
Suami/Istri /
Husband/Wife
Anak / Child

Anak / Child

Anak / Child
INFORMASI TAMBAHAN / ADDITIONAL INFORMATION
Gaji diharapkan / Expected Salary / Bulan / Month (required to be filled)

Kapan bisa bergabung ?

When will you be ready to join ?

Apakah anda WNI ? Y N If Not, do you have permit to work Y N

Do you citizen of Indonesia? in Indonesia?
Apakah pernah bekerja disini sebelumnya ? Y N Tahun dan posisi
Have you worked / applied in this company? Year and position

Do you have any family / friend working for Y N Sebutkan nama dan
this company? hubungan Anda / Mentioned name and relation status
Bersedia bekerja di Bontang ? Y N
Are you willing to work on Bontang site?

Bersedia bekerja lembur ? Y N

Are you willing to work overtime?

Pernah terlibat tindakan kriminal ? Y N Sebutkan / Mentioned it

Have you been involved in criminal case or violation of law?

Pekerjaan yang diminati 1. Kantor / Office Mengapa / Explain why

What kind of job do you prefer? 2. Lapangan / Field
3. Individual
4. Team
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Sebutkan kelebihan Anda / Mentioned your strenghs Sebutkan kelemahan Anda / Mentioned your weaknesses
1 1
2 2
3 3

Sebutkan capaian Anda dalam pekerjaan sebelumnya Sebutkan kegagalan Anda dalam pekerjaan sebeleumnya
Mentioned your achievement during in previous job : Mentioned your failure in previous job :

PERNYATAAN DAN TANDA TANGAN / STATEMENT & SIGNATURE

Saya menyatakan bahwa jawaban di atas benar. Apabila proses ini berakhir dengan penerimaan diri saya untuk bekerja
sebagai karyawan, Saya memahami bahwa kesalahan / kekeliruan informasi dalam dokumen dan interview saya
dapat berakibat pemutusan hubungan kerja.
I certify that my answer above are corect and complete. If this application ended by accepting and hiring me as an employee in this company,
I understand if misinformation or misleading information in my resume or interview may result termination

Nama & Tanda tangan Tanggal

Name & Signature Date