EMPLOYEE APPLICATION FORM

F – HRD/REC/0___/__/202_

The following information will help us assess your employment opportunity with CV. Pangan Inti Karya Indonesia
(hereinafter called the “Employer”). All portions of this application pertaining to you must be completed. We appreciate
the time you spend in completing this application form.

Position applied for Outlet Supervisor

: _______________________________
Recent
Other position(s) you would like to be considered for : ___________________
-
photograph
3 X 4 cm
Salary expectation : _______________________________
Rp. 4.700.000

Available starting date Able to join immediately

: _______________________________

PERSONAL DATA
Full name : Nindya Ayu Clodya Putri Male Female
Nick Name : Ciyo
Place / Date of Birth : Bekasi, 7 September 2001
Current Address : Jalan Bunisari No.14, Kuta, Bali
Jalan Bunisari No.14, Kuta, Bali
Nearby : Kuta Sari House
City : Bali Post code: 80361
Permanent Address : Jalan Merpati IV No.12-12A Tambun selatan, Bekasi

Nearby : Tambun Station

City : Bekasi Post code: 17510
Mobile Phone 1 : 085163225854
Mobile Phone 2 :
Home Phone :
Personal Email : nindyaclodyap@gmail.com

BPJS TK Number : BPJS Kes Number :

NPWP Number :
Driving Licence Number : A: C:
I.D. Card Number : 3216064709010015 Date of Expiry :-
Marital Status : Single M-0 M-1 M-2 M-3
Religion : Islam Blood Group : B
Height / Weight : 156/57 Hobby : Traveling & Cooking
Allergic :
EDUCATION AND TRAINING
Name and address of school, University or From To Degree or
Major Course or Study
other Training Institutions. (MM/YY) (MM/YY) Certificate
President University 2020 2024 Inter. Relations Bachelor's
OTHER ACTIVITIES
Name of Organisation From date To date Status

RECORD OF PREVIOUS EMPLOYMENT

1. Company Name : ____________________________________________
PT. Denso Manufacturing Telephone : _____________________
Address : _________________________________________________
Cikarang, Kab.Bekasi Position : Ass.Supervisor
_____________________
& Admin
Duties : Making
_________________________________________________________________________________
report every month, handle employees performance in 5 area, Record stock material
_________________________________________________________________________________
Nature of Business : _____________________________________
Otomotif
Employment dates : from ____________
Maret 2023 to ____________
April 2024 Supervisor’s Name : ______________________
Prajna Manggala
Salary : _________________________________
Rp. 5.700.000
Reason for leaving : _________________________________________________________________________
Finnished the Internship

2. Company Name : ____________________________________________

Dawend Coffee shop Telephone : _____________________
Address : _________________________________________________
Mekarsari, Kota Bekasi Position : _____________________
Supervisor Area
Duties : _________________________________________________________________________________
Lead service quality performance, monitor and analyze employees performance
_________________________________________________________________________________
Nature of Business : _____________________________________
F&B
Employment dates : from ____________
Feb 2022 to ____________
Jan 2023 Supervisor’s Name : ______________________
Almaidah
Salary : _________________________________
Rp. 3.800.000
Reason for leaving : _________________________________________________________________________

3. Company Name : ____________________________________________ Telephone : _____________________

Address : _________________________________________________ Position : _____________________
Duties : _________________________________________________________________________________
_________________________________________________________________________________
Nature of Business : _____________________________________
Employment dates : from ____________ to ____________ Supervisor’s Name : ______________________
Salary : _________________________________
Reason for leaving : _________________________________________________________________________

REFERENCES (Non – Relatives)

1. Name : ______________________ Telp/Mobile: _________________ Company : ______________________
E-Mail : __________________________________________________ Years Known : __________________

2. Name : ______________________ Telp/Mobile: _________________ Company : ______________________

E-Mail : __________________________________________________ Years Known : __________________

3. Name : ______________________ Telp/Mobile: _________________ Company : ______________________

E-Mail : __________________________________________________ Years Known : __________________

LANGUAGE PROFICIENCY
Language skills (Language spoken) :
Language Speaking Reading Writing
English Poo Goo Excellen Poo Goo Excellen Poo Goo Excellen
r d t r d t r d t
.................................... Poo Goo Excellen Poo Goo Excellen Poo Goo Excellen
. r d t r d t r d t
.................................... Poo Goo Excellen Poo Goo Excellen Poo Goo Excellen
. r d t r d t r d t

2
FAMILY RECORD
Father’s Name : ______________________________
Refly Age : _____
46 Occupation : _________________
Entrepreneur
Mother’s Name : ______________________________
Yohana Tumini Age : _____
45 Occupation : _________________
Supervisor
Permanent address : ______________________________________________________________________
Jalan Merpati IV No. 12-12A Tambun Selatan Bekasi
City : __________________________
Bekasi Telephone : _________________
Husband/Wife’s name: ____________________________ Place/DOB : _____________ Occupation : _________
First child : __________________________________ Place/DOB : _________________ Male Female
Second child : __________________________________ Place/DOB : _________________ Male Female
Third child : __________________________________ Place/DOB : _________________ Male Female

Contact person in case of emergencies : _____________________________

Daffa Indra Telephone : _________________
087875872712

GENERAL INFORMATION

Are you presently employed ? Yes No

Have you ever been discharged from employment? If yes, please explain
______________________________________________________________________________________________
______________________________________________________________________________________________

Have you any objection to our contacting your previous employers ? Yes No
Have you had any serious illnesses, injuries or operations within the last five (5) years? If so, please describe
______________________________________________________________________________________________
______________________________________________________________________________________________

Have you had been involved any accidents or losses (aviation) in the last five (5) years? Yes No
If Yes, please describe.
______________________________________________________________________________________________
______________________________________________________________________________________________

Have you had any criminal convictions or violations in the last five (5) years? Yes No If Yes, please describe.
______________________________________________________________________________________________
______________________________________________________________________________________________

Have you ever suffered from any of the following illnesses?

Tuberculosis Yes No Heart Disease Yes No
Hypertension Yes No Diabetes Yes No
Venereal Disease Yes No Epilepsy Yes No
Hepatitis Yes No HIV/AIDS Virus Yes No

DECLARATION :
I certify that all statements made on this application are true and complete to the best of my knowledge. I understand
that misrepresentation or omission when discovered, will subject me to discharge and I hereby authorize any
investigation relating to my work experience, education, or reputation for the purpose of my application for employment.

_________________ _________________
Tuesday, 19-11-2024
Applicant' signature Date