APPLICATION FOR EMPLOYMENT
An Equal Opportunity Employer
We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other
status protected by law or regulation. It is our intention that all qualified applicants be given equal opportunity
and that selection decisions be based on job-related factors.
Answer each question fully and accurately. No action can be taken on this application until you have answered all questions.
Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for signature on back of
application. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal
preferences or discrimination based upon non-job-related information.
Programmer
Job Applied for_____________________________________________________________ April 30, 2018
Today’s Date _________________________
Are you seeking: Full-time Part-time Temporary employment? May 1, 2018
When could you start work? ______________
Hafizallah Muhammad Ardian
_____________________________________________________________________________ 0897-8406-482
_______________________
Last Name First Name Middle Name Telephone Number
Perum. Citra Indah Block V7 No6 Cileungsi Bogor Indonesia 16830
________________________________________________________________________________________________________
Present Street Address City State Zip Code
Are you 18 years of age or older? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes ■ No
(If you are hired, you may be required to submit proof of age.)
3175040104930003 If hired, can you furnish proof you are eligible to work in the U.S.?
Social Security # __________________ Yes No ■
Have you ever applied here before? Yes No ■ If yes, when? __________________________________________
Were you ever employed here? Yes No ■ If yes, when? __________________________________________
Have you ever been convicted of any law violation? Include any
plea of “guilty” or “no contest.” Exclude minor traffic violations.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No ■
If yes, give details ___________________________________________________________________________________________
(A conviction will not necessarily disqualify an applicant for employment.)
If employed, do you expect to be engaged in any additional business
or employment outside of our job?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes ■ No
because, I am a teamwork person and also I am proficient in that field
If yes, give details ___________________________________________________________________________________________
For Driving Jobs Only: Do you have a valid driver’s license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes ■ No
1205170823914
Driver’s License Number _______________________________ A
Class of License_______ Indonesia
State Licensed In ___________
Have you had your driver’s license suspended or revoked in the last 3 years? . . . . . . . . . . . . . . . Yes No
If yes, give details: ____________________________________________________________________________________
List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal
race, color, religion, national origin, sex, age, disability or other protected status.) ____________________________________
I am the member of LP3I Computer Club
_____________________________________________________________________________________________________
Number of Diploma/
Subjects
LIST NAME AND ADDRESS OF SCHOOLS Years Degree/
Studied
Completed Certificate
High School or GED: _________________________________________________________________________________________________
College or University: ________________________________________________________________________________________________
LP3I Jakarta
Vocational or Technical: _____________________________________________________________________________________________
SMK Farmasi DITKESAD
What skills or additional training do you have that relate to the job for which you are applying? ____________________________
I am proficient in systems analyst, programming, and computer maintenance. I also proficient in analyst with SQL Server and Visual Studio.
____________________________________________________________________________________________________________________
What machines or equipment can you operate that relate to the job for which you are applying?____________________________
Computer, Laptop, and Gadget.
____________________________________________________________________________________________________________________
MSEC 1.1a (09/02)
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List names of employers in consecutive order with present or last employer listed first. Account for all periods of time
including military service and any periods of unemployment. if self-employed, give firm name and supply business
references. Note: A job offer may be contingent upon acceptable references from current and former employers.
NAME OF EMPLOYER JOB TITLE AND DUTIES
Mr. Ismail, S.E Student (Learning the lectures)
ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO
Jalan Raya Cileungsi Jonggol No.3 Cileungsi Kidul September 5, 2016
CITY, STATE, ZIP CODE
PAY: START $ FINAL $
Bogor, Indonesia,16820
SUPERVISOR(S) TELEPHONE Reason For Leaving
Mr. Fajar Choirul Hidayat, S.Kom 0896-8707-1557 I am Fresh Graduated
NAME OF EMPLOYER JOB TITLE AND DUTIES
ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO
CITY, STATE, ZIP CODE
PAY: START $ FINAL $
SUPERVISOR(S) TELEPHONE REASON FOR LEAVING
NAME OF EMPLOYER JOB TITLE AND DUTIES
ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO
CITY, STATE, ZIP CODE
PAY: START $ FINAL $
SUPERVISOR(S) TELEPHONE REASON FOR LEAVING
NAME OF EMPLOYER JOB TITLE AND DUTIES
ADDRESS DATES OF EMPLOYMENT (MO/YR): FROM TO
CITY, STATE, ZIP CODE
PAY: START $ FINAL $
SUPERVISOR(S) TELEPHONE REASON FOR LEAVING
Have you worked or attended school under any other names? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No ■
If yes, give names: _________________________________________________________________________________________
Are you presently employed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No ■
If yes, whom do you suggest we contact? ____________________________________________________________________
Have you ever been fired from a job or asked to resign? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No ■
If yes, please explain: _______________________________________________________________________________________
Give three references, not relatives or former employers.
Name Address Phone
________________________________________________________________________________________________________
Mr. Ismail, S.E Jl. Pitara Raya Kp. Pitara Gg. Swadaya No.18 Rt.04/16 Pancoran Mas 0818-164-794
________________________________________________________________________________________________________
Mr. Firdaus Sandatika, S.S Jalan Raya Cileungsi Jonggol No.3 Cileungsi Kidul 0895-1325-8815
________________________________________________________________________________________________________
Mr. Fajar Choirul Hidayat, S.Kom Kampung Cipicung RT 18 RW 04 Desa Mekarsari 0896-8707-1557
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further
consideration for employment and may result in my dismissal if discovered at a later date.
I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers
and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in
making such statements.
I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of
employment, if required.
I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to
the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.
I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED
CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY
TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE
EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH
OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.
I have read, understand, and by my signature consent to these statements.
Signature: ________________________________________________________________________________________________________________ Date: _________________________________
This application for employment will remain active for a limited time. Ask the organization’s representative for details.
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