PT PHARMATIA SKIN LAB

Jl. Raya Muchtar No. 70 Sawangan Baru Kota Depok 16511

Phone : (0251) 8613124

APPLICATION FORM
(Complete blanks with truth, as it will be the recruitment consideration)

APPLIED JOB/TITLE : ____________________________________________________________

Posisi Lamaran

PERSONAL DATA
Data Pribadi
Full Name/Nick Name :
Nama Lengkap/Panggilan
Current Address :
Alamat Lengkap
Phone :
Telepon
Religion :
Agama
Nationality :
Kebangsaan
Gender Height Weight Status Place & Date of Birth
Jenis Kelamin Tinggi Berat Status Tempat & Tanggal Lahir
Male Single Married Place Date Month Year
Pria cm kg Belum Kawin Kawin Tempat Tanggal Bulan Tahun
Female
Wanita Widow Others
Janda/Duda Lain lain
IDENTITY STATUS OF ADDRESS
Identitas Status Tempat Tinggal
Own House Room rent/board
KTP No. : Milik Sendiri Indekost

Parent's House Others

Milik Orang Tua Lain lain
SIM A/C No. :
Rent/Lease
Sewa/Kontrak
NPWP No. :

DO YOU HAVE A VEHICLE? Yes No

Apakah Anda Memiliki Kendaraan Pribadi?
Own Vehicle Parent's Vehicle Office's Vehicle Others
Milik Sendiri Milik Orang Tua Milik Kantor Lain lain

FAMILY MEMBERS (include yourself)

Susunan Keluarga (Termasuk diri sendiri)

Latest Occupation
Relationship Name M/F Age Education Pekerjaan Information
Hubungan Nama L/P Usia Pendidikan Position Company Keterangan
Terakhir Jabatan Perusahaan
Father
Ayah
Mother
Ibu
Sibling 1
Saudara 1
Sibling 2
Saudara 2
Sibling 3
Saudara 3
Sibling 4
Saudara 4
Sibling 5
Saudara 5

Application Form Page 1 of 4

 FAMILY MEMBERS (include yourself)
Susunan Keluarga (Termasuk diri sendiri)
Latest Occupation
Relationship Name M/F Age Education Pekerjaan Information
Hubungan Nama L/P Usia Pendidikan Position Company Keterangan
Terakhir Jabatan Perusahaan
Spouse
Suami/Istri
Child 1
Anak 1
Child 2
Anak 2
Child 3
Anak 3
Child 4
Anak 4

FORMAL EDUCATION BACKGROUND

Riwayat Pendidikan Formal / Informal
Period
Level Name of School City Major Pass/Fail
From To
Tingkat Nama Sekolah Kota Jurusan Lulus/Tidak
Dari Sampai
Prima
SD
Junior High
SMP
Senior High
SMA
Academy
Akademi
University
Universitas
Others
Lain lain

COURSES/TRAININGS
Kursus/Training
Name of Course Organizer City Period Year Certificate
Bidang Kursus Penyelenggara Kota Lama Kursus Tahun Sertifikat

LANGUAGE/COMPUTER (Excellent, Good, Fair, Average)

Pengetahuan Bahasa (Baik Sekali, Baik, Cukup, Rata-rata)
Skills Listening Reading Speaking Writing
Keahlian Mendengar Membaca Berbicara Menulis

ORGANIZATIONS/ACTIVITIES
Organisasi/Kegiatan
Name of Organization Kind of Organization Position Period
Nama Organisasi Macam Kegiatan Jabatan Periode

Application Form Page 2 of 4

 HOBBY & FREE TIME ACTIVITIES
Hobby & Kegiatan Di Waktu Luang

How Much Do You Read? What Kind of Topics Do You Read?

Anda Membaca Pokok yang dibaca
Many
Banyak
Fair
Cukup
Little
Sedikit
What magazine do you usually read:
Anda biasa membaca Surat Kabar/Majalah apa saja :

Newspaper : ...........................................................................................................................………..
Surat Kabar

Magazine : ....................................................................................................................................
Majalah

WORK HISTORY
Riwayat Pekerjaan
Period Company Position
Lama Bekerja Perusahaan Jabatan
Name : First :
From :
A Nama Awal
Dari
Address :
Alamat Last :
To :
Phone : Akhir
Sampai
Telpon
Line of business : Reasons for quitting :
Jenis Usaha Alasan Berhenti
Number of Employees : person
Jumlah Karyawan
Name of superior : Latest Salary (THP) : IDR
Nama Atasan Gaji Terakhir

Period Company Position

Lama Bekerja Perusahaan Jabatan
Name : First :
From :
B Nama Awal
Dari
Address :
Alamat Last :
To :
Phone : Akhir
Sampai
Telpon
Line of business : Reasons for quitting :
Jenis Usaha Alasan Berhenti
Number of Employees : person
Jumlah Karyawan
Name of superior : Latest Salary (THP) : IDR
Nama Atasan Gaji Terakhir

Period Company Position

Lama Bekerja Perusahaan Jabatan
Name : First :
From :
C Nama Awal
Dari
Address :
Alamat Last :
To :
Phone : Akhir
Sampai
Telpon
Line of business : Reasons for quitting :
Jenis Usaha Alasan Berhenti
Number of Employees : person
Jumlah Karyawan
Name of superior : Latest Salary (THP) : IDR
Nama Atasan Gaji Terakhir

Application Form Page 3 of 4

 OTHERS
Lain-lain

No QUESTION YES NO REMARKS

Pertanyaan Ya Tidak Penjelasan

1 Now in healthy physical and spiritual circumstances

(Pada saat sekarang dalam keadaan sehat jasmani dan rohani)

2 Is your condition currently in a state of disruption, need or surgery

recommended or in the care of a doctor or is undergoing a healing
process ?
(Apakah kondisi anda sekarang dalam keadaan terganggu, memerlukan
atau dianjurkan operasi atau dalam perawatan dokter atau sedang
menjalani proses penyembuhan ?)

3 Have you ever got serious illness or take intensive care? If yes please
mention the time and kind of illness
(Apakah anda pernah mengalami sakit keras atau menjalani perawatan
yang intensif?) Bila ya, kapan dan sebutkan penyakitnya

4 Have you ever got accident or surgeries? If yes, when have you had it?
Is it affect to your health condition right now?
(Apakah anda pernah mengalami kecelakaan? Bila ya kapan dan apa
akibat yang anda rasakan sekarang?)

5 Have you ever undergone psychological examination before? If so,

when, where, for what purpose?
(Apakah anda pernah menjalani pemeriksaan Psikologis? Bilamana,
dimana dan untuk tujuan apa?)

EMERGENCY CONTACTS
Orang Yg Dapat Dihubungi Dlm Keadaan Darurat
Name Address/Phone Occupation Relationship
Nama Alamat/Telpon Pekerjaan Hubungan

Depok, .........,....................201..

___________________________
Applicant Name & Signature

Application Form Page 4 of 4