PT.

Samsung SDS Global SCL Indonesia

Centennial Tower, 17th Floor, Suite A1
Jln. Gatot Subrto Kav 24 - 25
Jakarta Selatan, 12930
Phone : +62-21-2295-8066
Fax : +62-21-2295-8060

EMPLOYMENT APPLICATION PHOTO

POSITION APPLIED :

(1) PERSONAL INFORMATION

Full Name (BLOCK LETTERS) Underline Family Name Chinese Character (if applicable)

Local Address :

Foreign Address (if Applicable) :

Contact No : Mobile Phone :

Marital Status : Gender :

Date of Birth : Email Address :

Place of Birth : Race / Religion :

NRIC / Password No. : Dialect Group :

Nationality : PR Start Date :

Valid Driving License : No Yes

Driving License Type :
Completed Exempted
National Service :
Reason :

(2) HEALTH
Do you have any illness? If yes, please specify illness and period
ILLNESS PERIOD

(3) IMMEDIATE FAMILY INFORMATION

Name Age Relationship Occupation Compa
ny

(4) EDUCATION
 DATE
NAME OF INSTITUTION QUALIFICATION OBTAINED
FROM TO

(5) OTHER TRAINING

TYPE OF COURSE INSTITUTION QUALIFICATION YEAR COMPLETED

(6) OTHER SKILLS / COMPUTER KNOWLEDGE

(7) LANGUAGES PROFICIENCY

INDICATE:
LANGUAGE
FAIR / GOOD / EXCELLENT
SPEAK READ WRITE

(8) EMPLOYMENT HISTORY

Start with your present (or most recent) employer
Employment (Company Name) :

Job Title : Last Drawn Salary :

Date Joined : Date Resigned :

Job Description / Responsibilities :

Reason of Leaving :
 Employment (Company Name) :

Job Title : Last Drawn Salary :

Date Joined : Date Resigned :

Job Description / Responsibilities :

Reason of Leaving :
Employment (Company Name) :

Job Title : Last Drawn Salary :

Date Joined : Date Resigned :

Job Description / Responsibilities :

Reason of Leaving :
Employment (Company Name) :

Job Title : Last Drawn Salary :

Date Joined : Date Resigned :

Job Description / Responsibilities :

Reason of Leaving :

(9) COMPENSATION
Current Salary : (per Month)
Expected Salary : (per Month)
Earliest Join Date :

(10) REFERENCES
List two references (Relatives should not be included)
Occupation /
Name Years Known Contact Number
Company Name

(11) HOBBIES
(12) GENERAL (Please circle the appropriate
answers)

(a
Have you ever been convicted of a criminal offence? Yes / No
)
(b
Have you ever been dismissed or suspended from any service of any employer? Yes / No
)
(c) Are you a bankrupt / discharged bankrupt? Yes / No
(d
Have your attended any interview at Samsung before? Yes / No
)
if yes, please specify :
(e
Do you have any relatives or friends in our employment? Yes / No
)
if yes, please state name/position/relationship :

(f) Are you referred by an existing Samsung employee, please specify name: Yes / No

if yes, please specify name :

(g
Are you recommended by any employment agency? Yes / No
)
if yes, please state name and person-in-charge:

(13) DECLARATION

I declare that the information provided above is true and complete in all aspects. I understand that any misrepresentation or
omission of information may be considered sufficient for withdrawal of an offer or subsequent dismissal from employment.

Signature of Applicant Date

FOR OFFICIAL USE

1) 1st Interview Date By

2) 2nd Interview Date By

3) 3rd Interview Date By

* Accepted/Rejected/KIV until

Salary to offer Name

Increment after confirmation Signature

Join Date Date

* Please delete accordingly