Private & Confidential
EMPLOYMENT APPLICATION FORM
Please attach
photo here
4cm x 6cm
To:
Human Resource Department
Position applied for:
How did you learn about this vacancy:
Section A : Personal Information
MIFTAHUL ULUM
Full Name (capital letter): __________________________________________________
Sex: Male/Female
Date of Birth:
Februari 19, 1976
Kendal
________________________
Place of Birth: _______________________________
Islam
______________________________________________________________________
Religion
Full Address:
Pondok Sirnabaya Indah Blok A no. 1 RT 008/005 Sirnabaya. Karawang
_____________________________________________________________________
Contact Number:
085288601979
________________________ Hand Phone: _______________________________
Email Address:
miftahul1977@gmail.com
_____________________________________________________________________
ID Card Number:
3215011902760004
17-12-2015
Issued by: _________________ on:_____________
f _______________________
Passport Number:
________________________ Issued by: _________________ on:_____________
Marital Status:
Married
3 person
________________________
No. of Children: _____________________________
Family (including mother, father, brother, sister, spouse & children if any)
Name
Kanin
Relationship
Date of Birth
Occupation
Father
Aisyah
Mother
Ahmad Zamroni
Brother
Nurwahidah
Sister
Company
businessman
-
List two persons as your emergency contact.
Name
Dessy Herliani
Relationship
wife
Telephone
Mobile
082114207823
Address
Karawang
Section B : Education**
List below your last attendance at University/College/School
Institution(s)
From Year to Year
Place
Qualification
Obtained
Graduated
Singaperbangsa University
1998 - 2004
Karawang
STM N Kendal
1993 - 1996
Kendal
Pass
SPM N 1 Kendal
1990 -1993
Kendal
Pass
SD N Bandengan 1
1983 - 1989
Kendal
Pass
*) pick one by crossing the unnecessary information / **) Please attach certified copies of your certificates
Section C : Employment History
Provide information for the last 10 years, starting with the most recent employment. If space
provided is insufficient, please attach separate sheet.
Company
1
PT. Onamba Indonesia
From
(MM / YR)
June 2014
To
(MM / YR)
Present
Position(s) Held
Personnel & GA Head
Last Salary
IDR 13.000.000
Reasons for Leaving:
Duties/Responsibilities:
Manage and control Personnel and General Affairs departement's activities
May we contact this current / previous employer?
If yes, please provide name and contact number.
If not, please explain why.
2
Oct 1996
PT. Asia Pacific Fibers, Tbk
Got better salary
YES / NO
Firman Hidayat 081316546191
June 2014
HRD Ass. Manager
Reasons for Leaving:
Duties/Responsibilities:
Manage personnal matters example :HRIS, training & development, Absenteeism,
Industrial Relation,Health Insurance etc
May we contact this current / previous employer?
If yes, please provide name and contact number.
If not, please explain why.
YES / NO
Ujang Sarpendi 083814368272
3
Reasons for Leaving:
Duties/Responsibilities :
May we contact this current / previous employer?
If yes, please provide name and contact number.
If not, please explain why.
YES / NO
IDR 7.500.000
4
Reasons for Leaving:
Duties/Responsibilities
May we contact this current / previous employer?
If yes, please provide name and contact number.
If not, please explain why.
YES / NO
Section D: Skills and Training
List other skills or training that support this application
Skill / Training Course
Institution
Certification /
Proficiency
Year
MSDM for beginners profesional
HRD Club
Certificate of attendance
2014
HR Brotherhood super camp
HRD Forum
Certificate of attendance
2014
OD Specialist program
Value Consult
Certificate of competence
2012
Supervisory Management
SIS Consulting
Certificate of attendance
2012
English Business Course
Global Education
Level 1
2012
Section E: Languages
Language
English
Spoken*
Written*
Poor / Fair / Good
Poor / Fair /Good
Poor / Fair / Good
Poor / Fair / Good
Poor / Fair / Good
Poor / Fair / Good
Section F: References
List two persons not related to you, who are familiar with your character, background or work
performance, which we may contact at any time.
Name:
Address:
Name:
Address:
Firman Hidayat
_______________________________________
Contact No.:
081316546196
___________________________________
_______________________________________
PT. Onamba Indonesia
Occupation:
___________________________________
Production Manager
_______________________________________
Years Known:
2 years
___________________________________
Ujang Sarpendi
_______________________________________
Contact No.:
083814368272
___________________________________
PT. Asia Pacific Fibers
_______________________________________
_______________________________________
Occupation:
Years Known:
HRD
___________________________________
10 years
___________________________________
Section G : Other
Expected salary
Estimated date of join
IDR 16.000.000
one month after notice
Section H : Declarations and Authorizations
THIS APPLICATION IS NOT COMPLETED UNTIL THE FOLLOWING STATEMENT HAS BEEN READ AND SIGNED.
Have you ever been convicted of a criminal offence anywhere in the world, excluding
convictions that have been set aside or quashed? If yes, please provide details below.
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 or dismissal
from employment at DHL.
Details:
Yes
No
Yes
No
Yes
No
Have you ever been dismissed or suspended from any position, or subject to internal disciplinary
action by any of your previous employers? If yes, please state where, when, and cause.
Details:
Do you have any immediate family members working in this company? If yes, please state the
name of the employee, designation, and relation.
Details:
I certify that all the information provided in this application is true, complete and correct to the best of my knowledge. I
understand that any false information or omission may lead to dismissal or disciplinary action.
I authorize DHL (and its parent, subsidiaries, affiliates or agents) 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.
To the extent permissible under the law, I release DHL and all other persons, companies or organizations, from any and
all liability to me arising from providing or receiving such information relating to me. DHL will only use information
collected in connection with your employment with DHL.
MIFTAHUL ULUM
Karawang, March 15, 2016
Signature
Date
Thank you for completing our DHL Application Form
DHL- Supply Chain Indonesia
Graha Intirub Bussines Park Build, 1st floor
Jl.Cililitan Besar No. 454 East Jakarta 13650 INDONESIA
Tel +62 (0) 21 29379030 Fax +62 (0) 21 29379050
www.dhl.com
