Form Data Isian Pegawai Altius - V1 Rev

Recent Photo
(3x4)
CANDIDATE APPLICATION FORM

(Please fill with CAPITAL letter)
PERSONAL PROFILE
Full Name
Nick Name
Gender  Male   Female )*
Body Height & Weight Cm Kg

Blood Type  O   A   B   AB )*
Birthplace & Date of Birth
Nationality  Indonesian |  Foreigner )*
Ethnic  Bataknese |  Javanese |  Sundanese |  Chinese |  Others : )*
Religion  Buddhist |  Hindu |  Moslem |  Catholic |  Christian |  Others : )*
Marital Status  Single |  Married |  Divorce

)*
Cellphone Number
Phone Number
E-mail
NPWP Number
ID Card Number
ID Card Address
District : Province :
Current Address
District : Province :
Ownership  Own |  Boarding |  Parents |  Relatives |  Rent |  Others : )*
)* Please gives check sign (🗸)
FAMILY MEMBER
Relationship Complete Name Gender Birthplace, Date of Birth Education Phone Number
Father Male
Mother Female
Brother / Sister
Brother / Sister
Brother / Sister
NUCLEAR FAMILY
Relationship Full Name Gender Birthplace, Date of Birth Education Phone Number
Husband L
Wife P
Child
DLP-Altius-HRGA-FORM-2023.0001 2 / 11
REFERENCE
(Please fill with superior level or HR name in latest company)
Name Department Relationship Phone Number
EDUCATION
Degree Institution City Major From Until Title GPA
Elementary School
Junior High School
Senior High School
Diploma
Bachelor
Post Graduate
WORKING EXPERIENCE
(Starting from the latest company)
Starting Work Period Month Year Until Month Year
Company Name
Position
Bussiness Type
Address & Phone Number
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Supervisor Name
Latest Salary
Allowance
Exit Reason
Company Name
Position
Bussiness Type
Address & Phone
Number
Supervisor Name
Latest Salary
Allowance
Exit Reason
Job Applied
1. | or | 2.
Expected Salary
Rp. | until | Rp.
Join Date
FOREIGN LANGUAGE PROFICIENCY

Level of Mastery
Foreign Language (Poor, Fair, Good, Excellent )
Speaking Listening Writing Reading
EXPERTISE
Please gives check sign (🗸)
Type of Skills Beginner Intermediate Advance
1.
2.
3.
4.
5.
6.
7.
OTHER INFORMATION
SOCIAL ACTIVITY / ORGANIZATION
(Including organization's name, position/level, active period, and location)
INTEREST / HOBBY
HEALTH
OTHER QUESTION
Please circle which applied
1. Have you ever following psychological testing before? Yes / No
If yes, when and what is the purpose?
2. Are you willing to follow medical check up? Yes / No
3. Are you willing to follow 3 month probation? Yes / No
4. Are you willing to be placed in other city? Yes / No
5. Do you know any employee in this company? If yes, who is it?
6. What is your relationship with those names?
ASPIRATION
(Including desire, hope, or ambition in life)
PRINCIPLE / LIFE PHILOSOPHY
STRENGHT AND WEAKNESS
Please draw a chart to explain your recent / latest position level in the organizational structure
(Please write a short essay about your job description in your latest workplac
PERNYATAAN AUTENTIFIKASI INFORMASI
Saya menyatakan dan menjamin bahwa semua informasi di atas adalah benar dan saya tidak menyembunyikan fakta yang
sesungguhnya. Saya memberikan kewenangan kepada Altius Hospitals untuk menghubungi semua pihak yang bersangkutan untuk
keperluan verifikasi dan untuk mendapatkan informasi lainnya mengenai saya secara lisan maupun tertulis dari waktu ke waktu
apabila hal itu dianggap perlu. Apabila dikemudian hari ditemukan bahwa data yang saya sampaikan diatas tidak benar dan/atau
ada pemalsian, maka saya bersedia dihilangkan haknya sebagai karyawan Altius Hospitals dan dikenakan tuntutan perdata dan
pidanasesuai ketentuan hukum dan perundang-undangan yang berlaku.
Jakarta,
Nama lengkap
FORM KELENGKAPAN KARTU KARYAWAN
*diisi oleh HRD

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Recent Photo

CANDIDATE APPLICATION FORM

Gender  Male   Female )*

Body Height & Weight Cm Kg

Birthplace & Date of Birth

Nationality  Indonesian |  Foreigner )*

Ethnic  Bataknese |  Javanese |  Sundanese |  Chinese |  Others : )*

Religion  Buddhist |  Hindu |  Moslem |  Catholic |  Christian |  Others : )*

Marital Status  Single |  Married |  Divorce

Ownership  Own |  Boarding |  Parents |  Relatives |  Rent |  Others : )*

)* Please gives check sign (🗸)

Name Department Relationship Phone Number

Degree Institution City Major From Until Title GPA

Junior High School

Senior High School

Starting Work Period Month Year Until Month Year

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

Starting Work Period Month Year Until Month Year

Address & Phone Number

FOREIGN LANGUAGE PROFICIENCY

Type of Skills Beginner Intermediate Advance

1. Have you ever following psychological testing before? Yes / No

If yes, when and what is the purpose?

2. Are you willing to follow medical check up? Yes / No

3. Are you willing to follow 3 month probation? Yes / No

4. Are you willing to be placed in other city? Yes / No

5. Do you know any employee in this company? If yes, who is it?

6. What is your relationship with those names?

PRINCIPLE / LIFE PHILOSOPHY

STRENGHT AND WEAKNESS

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