JOB APPLICATION FORM
Application will be kept strictly confidential. Complete all entries in BLOCK LETTERS.
Insert “DNA” if question does not apply
POSITION APPLIED FOR
Retail assistant
1. _____________________________ OR 2. _____________________________
PERSONAL PARTICULARS
PHOTO
Lim Zu Yi
Full Name: _________________________________________________________
16,jalan lapangan raya 3,Taman lapangan raya ,31650
Address: ____________________________________________________________________
Ipoh,Perak
___________________________________________________________________________
060525080432
IC No: (New) _____________________________ (Old) _____________________
(Malaysia Identity Card No)
Home: ______________ 0185783881
Mobile: _______________ yiyi5198yi@gmail.com
Email: ______________________
Cina Buddha
Gender: Male / Female Race: _________________ Religion: ____________________
Marital Status: Single / Married / Divorced / Widow
FAMILY PARTICULARS
Spouse Father Mother
Name
Lim Chee Fong Koo Lai Leng
IC No (New)
Designation Mechanic House wife
Employer’ Name LCF Mechanic
Employer’s
Address
0185783881
Contact No 0165536959 0165536746
文
Your Children
Name IC No (New) Gender Tax Relief
(Malaysia Identity Card No) (F/M) (Yes/No)
1.
2.
3.
4.
5.
PERSON TO CONTACT IN CASE OF EMERGENCY
Lim Chee Fong
Full Name: _________________________________________________________
16,jalan lapangan raya 3,taman lapangan raya,31650,Ipoh
Address: ____________________________________________________________________
Perak
___________________________________________________________________________
0165536959
Contact No: ___________________ Father
Relationship: ______________________
STATUTORY REFERENCES
KWSP No: ___________________________ PERKESO No: ____________________________
INCOME TAX No: _____________________ INCOME TAX Branch: _____________________
PAYROLL DETAIL
Bank Name: Public bank
______________________ Saving account
Account Type: ___________________________
Account No: ______________________
REFERRAL
If you were referred by a HTM Staff for this job application, please provide
HTM Staff Name: _________________________
HTM Staff IC No: _________________________
EMPLOYMENT RECORD
(List all work experience beginning with your present or last employment)
Last Draw Reason for
Name & Address of Employer From To Designation
Salary Leaving
REFEREES
Please name two person (not relatives) to who reference can be sourced
Name:__________________________________ Name:_____________________________
Designation: _____________________________ Designation: _______________________
Address:________________________________ Address:___________________________
_______________________________________ __________________________________
_______________________________________ __________________________________
Tel :___________________________________ Tel :______________________________
WORK EXPECTATION
Notice of resignation required for present employment ___________ month (s)
Willing to relocate: Yes / No
Current Salary: RM____________
Expected Salary: RM____________
EDUCATION BACKGROUND
School/College/University From To Certificates Obtained
LANGUAGE PROFICIENCY
(Proficiency is rated from 1 to 5, 5 being the highest level)
Other
Language English Malay Chinese
_____________
Spoken
Written
GENERAL INFORMATION
Have you ever been convicted for any criminal Yes No
offence in any Court of Law, whether in Malaysia or
overseas?
(If yes, please provide details)
Do you have any cases with the Labour Office / Yes No
Industrial Relations Office / Court
(If yes, please provide details)
Have you suffered from or are you currently suffering Yes No
from illness requiring regular medication
(If yes, please provide details)
Do you have any disabilities, physical or otherwise? Yes No
(If yes, please provide details)
Are you currently pregnant? (for female candidates) Yes No
(If yes, please provide details)
Do you have a member of your family/relative/friends Yes No
working with HTM Pharmacy Group?
(If yes, please provide details)
Full Name: IC No:
DECLARATION
1) I declare that the information given in this application is true and accurate. My employment may be based on
receipt of satisfactory information from former employers, schools and other references. Enclosed are copies
of my education / professional qualification certificate/ diploma / degree and /or appropriate
recommendation letters. If I am selected / employed, I will report to Human Resources Department the
changes or additions taking place from time to time. I understand that any misrepresentation of facts given
(including any uninformed changes) will be sufficient cause for denying employment or summary dismissal
from the company’s services if I have been employed.
2) I authorise the Group to conduct relevant background checks (including but not limited to financial check),
without liability, in consideration of my application for employment.
3) I agree that if a suitable position is not presently available within the Group, the Group may retain my
application and Personal Data for such period as the Group considers appropriate, in case a position that may
be suitable later becomes available.
Date: __________ Name: __________________________Signature: _______________
FOR COMPANY USE ONLY
SOURCE OF REFERRAL:
Newspaper / Company’s website / others (please specify):____________________________
Interviewed by: __________________________________Date: _______________________
Comments: _________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Further Interviewed by: ____________________________Date: _______________________
Comments: _________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Recommendation: SUCCESSFUL KIV REJECTED __________
Position Offered: _________________________
Date to commence: ___________________ Permanent Contract Others_________
During probation:
Salary: RM______________per month(s)
Allowance: RM ___________ per month(s) Probationary period: ________month(s)
Upon Confirmation:
Salary: RM______________per month(s)
Allowance: RM ___________ per month(s)
Reference Check: Yes No
