FIRMA SAMAHITA WIROTAMA

Jakarta. One Pacific Place 15th fl.

Jl. Jendral Sudirman Kav. 52-53, Jakarta 12190
Surabaya. Jl. Dharmahusada Megah Permai Kav 36,
Surabaya 60115
Phone : (031) 594 8990
www.samahitawirotama.com

No Ref: HRGA-014-I-13
EMPLOYMENT APPLICATION FORM
(Private & Confidential)

Post Applied For: Company:

Where did you learn of this vacancy? Jobsdb Jobstreet Others: __________________________________________________
Recommended by friend or relative: (name and relationship) ______________________________

PERSONAL PARTICULARS

Name (as per ID)

(pls underline surname)

Home Address

Domicile Address

Date of
Age ID No.
Birth Recent Passport-sized
Place of Photograph
Nationality
Birth

Sex Race Religion

Marital Mobile
Home No.
Status No.

Email Website

EDUCATION (please enclose copies of certificates and transcripts)

Name of Institution / School From To Course Taken Score

TRAINING

Name of Training From To Name of Training Institution Achievement

FAMILY DETAILS (please list your immediate family members)

Name Relationship Age Occupation Employer

EMERGENCY CONTACT(S)

Name Relationship Contact Number(s)

LANGUAGE PROFICIENCY AND COMPUTER SKILLS

Languages spoken:

Languages written:

PC Skills:

INTERESTS AND HOBBIES

EMPLOYMENT HISTORY (start with the most recent employment)

Company From To Position Held Reason for Leaving Salary

REMUNERATION DETAILS (based on current/last drawn package) *please enclose last pay slip salary

Current Allowance Commission/ Other benefits

Salary drawn Bonus

EXPECTED REMUNERATION
Expected Salary Allowance Commission/ Other benefits
Bonus
ORGANIZATION CHART
(please draw your present company’s organization chart showing your current position and those of your supervisors, peers and subordinate)

REFERENCES
( Please provide the following information of 2 referees who are your previous immediate supervisor)
Years
Name Designation and Company Contact Number
known

Do you have any objections if we conduct a reference check with these If yes, any
Yes / No
referees or other past employers? specific reasons:

FURTHER INFORMATION

If yes, pls
Do you have any physical impairment, disease or pre-existing illness? Yes / No
specify:
Have you ever been terminated, dismissed, suspended, asked to resign or If yes, pls
Yes / No
subjected to disciplinary action of any kind by any previous employers? specify:
If yes, pls
Have you ever been convicted in a Court of Law in any country? Yes / No
specify:
Have you ever been made bankrupt or have proceedings been taken to make If yes, pls
Yes / No
you one? specify:
If yes, pls
Do you own a vehicle? Yes / No
specify:
If yes, pls
Do you own any driving / motor bike licenses? Yes / No
specify:
Do you have any relatives or friends working in ________________________ Name / Occupation /
Yes / No
or any of its subsidiaries? Dept / Relsp

DECLARATION
I hereby declare that the information given by me in this form is correct and true to the best of my knowledge. I understand that any
misrepresentation or omission of facts called for herein will be sufficient cause for cancellation of consideration for employment or dismissal
from the company.

____________________________________ ________________________________
Applicant’s Signature Date