EMPLOYMENT APPLICATION FORM
POSITION APPLICATION
1. POSITION APPLIED : DATE OF INTERVIEW
2. HOW DID YOU FIND THIS VACANCY ?
LinkedIn Recruitment Agency/Headhunter Direct Application Others, please mention ____________
Facebook Jobstreet Staff Referral
PERSONAL DATA
1. FULL NAME DIKA ADHI SRIWIGUNA
2. SEX MALE
3. PLACE DATE OF BIRTH CILACAP
4. DATE OF BIRTH MARCH 13, 1998
5. MARITAL STATUS MARRIED
6. RELIGION ISLAM
7. NATIONALITY INDONESIA
8. ID CARD/PASSPORT NUMBER 3204321303980001
9. NPWP NUMBER 95.771.058.5-413.000
10. SOCIAL SECURITY NUMBER (BPJS KETENAGAKERJAAN) 0001195792334
11. CURRENT ADDRESS JL.LASWI BALEENDAH RT09/RW 04 BALEENDAH, BALEENDAH KAB.BANDUNG
12. PERMANENT ADDRESS (AS PER ID CARD) JL.LASWI BALEENDAH RT09/RW 04 BALEENDAH, BALEENDAH KAB.BANDUNG
13. CONTACT NUMBER MOBILE 1 : '0881023892812
MOBILE 2
RESIDENCE
14. EMAIL dikaadhi43@gmail.com
15. SOCIAL MEDIA LINKEDIN
FACEBOOK : DIKA ADHI SRIWIGUNA
INSTAGRAM dikaas13
TWITTER Dasrn2
FAMILY INFORMATION (for married individual, please fill in spouse & children data)
No Name Sex Relationship Education/ Occupation/ Company
1. RINA NURHADIYANSYAH FEMALE WIFE
PARENTS AND RELATIVES DATA (for single individual, please fill in family members information)
No Name of Parents and Relatives Sex Relationship Date of Birth City Education/ Occupation
EMERGENCY CONTACT
No Name Relationship Address Phone Number(s)
EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 1
FORMAL EDUCATION
Qualification
No School/ Institution City Year of Graduation Major GPA
Obtained
1. TK TERPADU BALEENDAH BANDUNG 2004
2. SDN 2 BALEENDAH BANDUNG 2010
3. SMPN 2 BALEENDAH BANDUNG 2013
4. SMKN 2 BALEENDAH BANDUNG 2016 CHEMICAL INDUSTRY
DIII ANALIS KESEHATAN STIKes
5. BANDUNG 2019 ANALIS KESEHATAN
RAJAWALI BANDUNG
LANGUAGE
No Language Spoken Written Reading
1. ENGLISH LOW LOW MODERATE (Low/ Moderate/ High)
2. INDONESIA HIGH HIGH HIGH (Low/ Moderate/ High)
(Low/ Moderate/ High)
PROFESSIONAL LICENSES OR CERTIFICATION
No Name of Certification Name of Institution Years Obtained
WORK EXPERIENCE
Current Company
KLINIK KIMIA FARMA 43 BUAH BATU
Company Name
Company Address JALAN BUAH BATU NO.259 TURANGGA, LENGKONG, BANDUNG
Latest Position
ANALIS KESEHATAN
Date (DD/MM/YYYY) Start Date End Date
Starting Salary Nov-21
Latest Salary UNTIL NOW
Reason for leaving
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why
Achievement(s)
Previous Company
RS HOSANA MEDICA LIPPO CIKARANG
Company Name
Company Address JALAN UTAMA BIIE NO.1 LIPPO CIBATU, CIKARANG SELATAN KAB.BEKASI
Latest Position
ANALIS KESEHATAN
Date (DD/MM/YYYY) Start Date End Date
Starting Salary Nov-19
Latest Salary Oct-21
Reason for leaving CONTRACT ENDED
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why
Achievement(s)
EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 2
Previous Company
Company Name
Company Address
Latest Position
Date (DD/MM/YYYY) Start Date End Date
Starting Salary
Latest Salary
Reason for leaving
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why
Achievement(s)
ORGANIZATION STRUCTURE
(please draw organization structure showing your position in your current company)
REFERENCES
List two person NOT related to you, who are familiar with your character, background or work performance (preferably your direct supervisor)
Name : TATANG ABDURACHMAN Contact No : +62813-2076-6572
Company : PT.KIMIA FARMA Job Position :
DIAGNOSTIKA
Years Known : 2021
Relationship :
Name : Contact No :
Company : Job Position :
Years Known :
Relationship :
CURRENT DETAILS OF SALARY AND BENEFITS
1. Monthly basic salary gross 4.000.000 IDR
2. Eligible for over time ? YES ( Yes / No )
If yes, monthly average ?
3. Allowances
Meal
Transportation 600.000 / bln IDR
Phone/ Handphone 100.000 / bln IDR
Others IDR
4. Loan facilities Type of Loan Housing Car Personal
Outstanding Amount Max Limit
Interest per Year % Outstanding Period (months/ years)
Repayment Methods (months/ years)
5. Annual Leave 12 (Days)
6. Annual Bonus :
THR (Festive Allowance) 4.000.000 IDR
Performance Bonus 1.000.000 IDR
Others, please explain IDR
EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 3
7. Medical Benefits Cashless ✓ Reimburstment
Out Patients (Per Year) IDR
In Patients (Room & Board) IDR
8. Life Insurance IDR
9. Other Benefits, Please Explain:
COMPENSATION BENEFIT EXPECTATION & COMMENCEMENT
1. Monthly salary (Gross) IDR
2. Benefits / Others
3. If you are offered employment with us
when can you start work (or notice period) ?
DECLARATIONS AND AUTHORIZATIONS
1. Do you have any family members; as an employee, who working in this company? (Yes/ No)
If yes, please state the name of the employee, designation and relation.
2. Have you ever been dismissed or suspended from any position, or subject to internal disciplinary action by any of your
previous employers? (Yes/ No)
If yes, please state where, when and cause
3. Have you ever been convicted of a criminal offence anywhere in the world, excluding convictions that have been set aside
or quashed? (Yes /No)
If yes, please provide details.
Disclosure of a criminal record will not necessarily disqualify you for employment. However failure to disclose such information may result in disqualification of your
application of dismissal from employment at MAYAPADAHEALTHCARE GROUP
4. Have you ever apply/ work in MAYAPADA HEALTHCARE GROUP? (choose one) (Yes/ No)
If yes, When ? For position ?
Where Last selection stage (for apply)
5. Are you currently holding any position in any political party or a candidate for any political office?
If yes, please provide the detail of position and political party and your joining date to that political party and the position that you are running for as candidate.
6. Is there any member of your immediate family an official or any government agency, an employee of any government agency,
an official of political party, or a candidate for political office?
If yes, please states the detail of the name, position/office held and the family relationship. Immediate family means husband, wife, children, mother, father, siblings.
7. Do you have any other job or business activities outside the current employment?
If yes, please provide the detail including name of enterprise, type of business, position and starting year of the position.
I certify that all the information provided on this application is true and complete to the best of my knowledge.
I understand that any false information or omission may lead to disciplinary action or summary dismissal without any compensation.
I authorize MAYAPADA HEALTHCARE GROUP to verify all information provided in this application, including employment history, educational background and references.
I authorize my previous employers and references indicated above to release any information they may have about me.
MAYAPADA HEALTHCARE GROUP will only use information collected in connection with my employment with MAYAPADA HEALTHCARE GROUP.
Signature & Name
To the extent required by law, you may request to review and correct personal data through the HR Department.
EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 4
