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SASTCM-F-HR-003

EMPLOYMENT APPLICATION FORM


FORMULIR LAMARAN KERJA

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NAME YOHANES LAWING
Nama .

FIRST ( pertama ) MIDDLE ( tengah ) LAST ( akhir )


SAMARINDA APRIL 27 1978
PLACE AND DATE OF BIRTH .
Tempat dan tanggal lahir
PLACE MONTH DATE YEAR
Tempat Bulan Tanggal Tahun

CIVIL STATUS : SINGLE MARRIED DIVORCED WIDOW (ER)


Status sipil Bujangan Kawin Bercerai Janda/Duda

NATIONALITY : . RELIGION : .
Kewarganegaraan Agama

ADDRESS : NUMBER STREET CITY - COUNTRY PHONE


Alamat Nomor Jalan Kota - Negara Telpon

CURRENT ADDRESS : .
Alamat sekarang .

PERMANENT ADDRESS : .
Alamat tetap .
E-MAIL ADDRESS : .
Alamat e-mail .

PUT IN X IN THE CORRECT RESPONSE BOX


Berikan tanda X pada kotak jawaban yang tepat

DO YOU : Yes No
Apakah Anda Ya Tidak

1. OWN A HOUSE ?
Memiliki rumah ?

2. OWN A PLOT OF LAND ?


Memiliki sebidang tanah ?

3. OWN A CAR
Memiliki mobil ?

4. OWN A MOTORCYCLE
Memiliki sepeda motor ?

5. RENT A HOUSE
Menyewa rumah ?

6. RESIDE IN HOUSE OWNED BY THE COMPANY


? Tinggal di rumah milik perusahaan ?

7. USE A CAR OWNED BY THE COMPANY


? Memakai mobil milik perusahaan ?

Effective Date: 01 July 2011


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OCCUPATION
NAME DATE OF BIRTH GENDER HIGHEST EDUCATION Pekerjaan
Nama Tanggal Lahir Pendidikan terakhir POSITION COMPANY
Posisi Perusahaan

SPOUSE CHRISTIANY PELSIUS 16-02-1983 P SARJANA HUKUM STAFF DPRD KUTAI BARAT
( Suami/Istri )

FATHER BERNARDUS BAYO 30-10-1957 P STM N/A N/A


( Ayah )

MOTHER MILAWATI 12-11-1962 P SKKP N/A N/A


( Ibu )
BROTHERS/SISTERS
(Saudara kandung)
INCLUDING YOURS
(Termasuk Anda)

1 YOHANES LAWING 27-04-1978 L SARJANA HUKUM N/A N/A

2 MARTINA MELIANA 15-05-1983 P SARJANA (Spd) STAFF BID HUKUM DPRD KUTAI BARAT

3 YAKOBUS KRISTIAN 26-07-1987 L DIII STAFF HR PT. MAMAHAK COAL MINING

4 MARTHA YOHANA 12-03-1997 P SMU N/A N/A

CHILDREN
(Anak - anak)
1 FELICIA DELLIN 22-07-2004 P SMP N/A N/A

2 MICHAEL EDWIN 26-04-2008 P SD N/A N/A

3 THERESIA ORCHID 14-07-2012 P TK N/A N/A

EDUCATION (LIST ALL SCHOOLS ATTENDED)


Pendidikan (Sebutkan semua pendidikan yang diikuti)

INCLUSIVE DATES
SCHOOL NAME OF SCHOOL AREA OF SPECIALIZATION Tahun Pendidikan
Sekolah Nama sekolah Jurusan FROM TILL
Dari Sampai

PRIMARY SD-009 - 1985 1991


S.D

JUNIOR HIGH SCHOOL SMP - 1991 1994


S.L.T.P

SENIOR HIGH SCHOOL SMA SOCIAL 1994 1997


S.L.T.A

ACADEMY/UNIVERSITY COLORADO ENGLISH 1998 2000


Akademi/Universitas

ACADEMY/UNIVERSITY UNTAG45/KARTINI HUKUM 2005 2009


Akademi/Universitas

Effective Date: 01 July 2011


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TCM-F-HR-003

TRAINING/COURSES
Pelatihan/Kursus

NAME OF INSTITUTION SUBJECT CITY DURATION FINANCED BY


Nama lembaga Bidang Kota Lama kursus Dibiyai oleh

Pusdiklat DTMB-ESDM Pengelola SMK3 Tambang Bandung 4 Days PT. Trubaindo Coal Mining
Pusdiklat DTMB-ESDM Pengawas Operational Pertama POP Samarinda 3 Days PT. Trubaindo Coal Mining
Pusdiklat DTMB-ESDM Pengawas Operational Madya POM Samarinda 4 Days PT. Mamahak Coal Mining
Pusdiklat DTMB-ESDM Pengawas Operational Utama POU Jakarta 4 Days PT. BK Global Lestari
PT. Wira Handal Mandiri Modern Safety Management System Jakarta 3 Days PT. Trubaindo Coal Mining
Dale Carnegie & Associates Fundamental Leadership Training Balikpapan 2 Days PT. Trubaindo Coal Mining
Banpus Legal Seminar on Contract
BANPU Management System - CMS Site Adong 1 Day PT. Trubaindo Coal Mining
PT. Star Safety Basic Safety Management Balikpapan 3 Days PT. Trubaindo Coal Mining
PT. Pinasthika Sasura Peningkatan Karya Prestatif ( PKP-I ) Tenggarong 3 Days PT. Trubaindo Coal Mining
PT. Indo Tambangraya Megah OHSAS 18001/18002 Overview Jakarta 1 Day PT. Trubaindo Coal Mining
PT. Indo Tambangraya Megah Contractor EHS Management System Jakarta 1 Day PT. Trubaindo Coal Mining

STATE WHAT LANGUAGES YOU SPEAK : Indonesia, English ..


Bahasa - bahasa yang anda dapat Bicara

READ : Indonesia, English ..


Membaca

WRITE : Indonesia, English


Menulis

EMPLOYMENT HISTORY :Give your employment history as completely and accurately as possible beginning from the present or last
employment

RIWAYAT PEKERJAAN :Ceritakan riwayat pekerjaan anda secara lengkap dan benar mulai dari pekerjaan sekarang atau terakhir

A. SERVICES YEAR NAME/ADDRESS/PHONE OF FIRM POSITION


Masa kerja Nama/Alamat/Telpon Perusahaan Jabatan
MONTH YEAR
Bulan Tahun
FROM PT. KELIAN EQUATORIAL MINING
Dari Oct 2000 Site Kelian Dalam, Kec. Long Iram Safety Administror

TO May 2001
Sampai

TYPE OF BUSINESS : GOLD MINING. TOTAL EMPLOYEES : 5000


Jenis Usaha Jumlah karyawan

LINE SUPERVISOR : KRISNAHADI DIRECTOR : CHARLIE LENEGAN


Atasan langsung Direktur

REASON OF RESIGNATION
Alasan Berhenti : JOB COMPLETE.

DESCRIBE DUTIES AND RESPONSIBILITIES IN YOUR CURRENT/LAST POSITION


Uraikan tugas dan tanggung jawab anda pada jabatan yang terakhir

- Data Admin, Work Permits, Preparing monthly reports quarter report, annual report, Safety inspections and patrol, Fleets
commissioning, Involved Safety meeting, Conducted Safety induction, Prepared report of monthly report, Involved safety
investigation, Member of fire warden, and.
- Being secretary of mine operation safety committee.
- AWAS (Audit Worker Attitudes to Safety) performances.

WHAT WORKING APPARATUS CAN YOU OPERATE ? : COMPUTER , PHOTO COPY, SCANNER, OHP.
Alat-alat kerja apakah yang dapat anda pergunakan ?
Effective Date: 01 July 2011
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CM-F-HR-003

B. SERVICES YEAR NAME/ADDRESS/PHONE OF FIRM POSITION


Masa kerja Nama/Alamat/Telpon Perusahaan Jabatan
MONTH YEAR
Bulan Tahun
FROM
Dari MAY 2001 PT. PETROSEA Tbk SAFETY OFFICER

TO
Sampai JULY 2004

TYPE OF BUSINESS : MINING & CONSTRUCTION CONTRACTOR TOTAL EMPLOYEES : 150


Jenis Usaha Jumlah karyawan

LINE SUPERVISOR : SUPRIANTO DIRECTOR : EDDIE HENOCH


Atasan langsung Direktur

REASON OF RESIGNATION
Alasan Berhenti : NEW CHALLENGE.

DESCRIBE DUTIES AND RESPONSIBILITIES IN YOUR CURRENT/LAST POSITION


Uraikan tugas dan tanggung jawab anda pada jabatan yang terakhir

Safety Induction, Site Inspection, Mine Inspection, Workshop Inspection, Office Safety, Fire
Extinguisher Inspection, Preparation EHS Audit, Incident Investigation, Toolbox Meeting, Weekly
Meeting, Committee Meeting, Preparation Weekly Report, Preparation Monthly Report, Prepare
EHS Training, Emergency Response.

WHAT WORKING APPARATUS CAN YOU OPERATE ? : COMPUTER


Alat-alat kerja apakah yang dapat anda pergunakan ?

C. SERVICES YEAR NAME/ADDRESS/PHONE OF FIRM POSITION


Masa kerja Nama/Alamat/Telpon Perusahaan Jabatan
MONTH YEAR
Bulan Tahun
FROM

Dari FEBRUARY 2005 PT. TRUBAINDO COAL MINING SAFETY MANAGEMENT SYSTEM SPV

TO
Sampai JULY 2009

TYPE OF BUSINESS : COAL MINING PKP2B TOTAL EMPLOYEES : 650


Jenis Usaha Jumlah karyawan

LINE SUPERVISOR : DEDDY SUGIHARTO. DIRECTOR : SOMYOT


Atasan langsung Direktur

REASON OF RESIGNATION
Alasan Berhenti : NEW CHALLENGE.

DESCRIBE DUTIES AND RESPONSIBILITIES IN YOUR CURRENT/LAST POSITION


Uraikan tugas dan tanggung jawab anda pada jabatan yang terakhir

Develop Safety Procedure, Safety Induction, Site Inspection, Mine Inspection, Workshop Inspection, Office
and Jetty Inspection, Fire Extinguisher Inspection, Preparation EHS Audit, Incident Investigation, Toolbox
Meeting, Weekly Meeting, Committee Meeting, Preparation Weekly Report, Preparation Monthly Report,
Prepare EHS Training, Emergency Response, Speed Gun.

WHAT WORKING APPARATUS CAN YOU OPERATE ? : COMPUTER, SPEED GUN.


Alat-alat kerja apakah yang dapat anda pergunakan ?
Effective Date: 01 July 2011
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TCM-F-HR-003

D. SERVICES YEAR NAME/ADDRESS/PHONE OF FIRM POSITION


Masa kerja Nama/Alamat/Telpon Perusahaan Jabatan
MONTH YEAR
Bulan Tahun
FROM
Dari JULY 2009 PT. MAMAHAK COAL MINING HSE SUPERINTENDENT / WKTT

TO
Sampai AGUSTUS 2011

TYPE OF BUSINESS : COAL MINING COMPANT - IUP TOTAL EMPLOYEES : 400


Jenis Usaha Jumlah karyawan

LINE SUPERVISOR : BAMBANG HERUTOMO DIRECTOR : ROBERT WATCHO


Atasan langsung Direktur

REASON OF RESIGNATION
Alasan Berhenti : SLOW DOWN.

DESCRIBE DUTIES AND RESPONSIBILITIES IN YOUR CURRENT/LAST POSITION


Uraikan tugas dan tanggung jawab anda pada jabatan yang terakhir

WHAT WORKING APPARATUS CAN YOU OPERATE ? :


Alat-alat kerja apakah yang dapat anda pergunakan ?

E. SERVICES YEAR NAME/ADDRESS/PHONE OF FIRM POSITION


Masa kerja Nama/Alamat/Telpon Perusahaan Jabatan
MONTH YEAR
Bulan Tahun
FROM
Dari AGUSTUS 2011 PT. KEDAP SAYAAQ KEPALA TEKNIK TAMBANG

TO
Sampai JUNI 2013

TYPE OF BUSINESS : COAL MINING COMPANY TOTAL EMPLOYEES : 150


Jenis Usaha Jumlah karyawan

LINE SUPERVISOR : KIM KWANG BINE. DIRECTOR : LEE JOUNG HUEON


Atasan langsung Direktur

REASON OF RESIGNATION
Alasan Berhenti : SLOW DOWN

DESCRIBE DUTIES AND RESPONSIBILITIES IN YOUR CURRENT/LAST POSITION


Uraikan tugas dan tanggung jawab anda pada jabatan yang terakhir

Fokus pada tugas-tugas KTT, SMK3 Tambang, Perlindungan Lingkungan, Kepatuhan Perijinan,
Pembuatan Laporan RKAB, UPL/UKL, Rencana Reklamasi, Rencana Penutupan Tambang,
Rehabilitasi Lahan, Laporan Exploitasi Triwulan dan Tahunan, Penempatan Jaminan Reklamasi,
Laporan Pengangkutan dan Penjualan SKAB.
WHAT WORKING APPARATUS CAN YOU OPERATE ? :
Alat-alat kerja apakah yang dapat anda pergunakan ?

Effective Date: 01 July 2011


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REFERENCES - GIVE FOUR (4) PERSONAL (NOT RELATIVES), FORMER EMPLOYERS OR FORMER
TEACHERS Referensi - Sebutkan empat (4) orang bukan famili/kerabat, mantan majikan/atasan atau mantan guru

NAME ADDRESS & PHONE OCCUPATION

Krisnahadi 0811-557725 Mine Manager PT.KEM


Bambang Herutomo 0821-5541-6273 GM Operation PT. MCM
Deddy Sugiharto 0812-5537-534 QSE Manager PT. TCM
Harris 0811-5835-571 KTT- PT. Kedap Sayaaq

HOBBIES AND ACTIVITIES


Hobi dan kegiatan di waktu luang

MEMANCING

SCHOOL/SOCIAL ORGANIZATION ACTIVITIES ( GIVE NAME OF ORGANIZATIONS )


Aktivitas sekolah/organisasi sosial (Sebutkan nama-nama organisasi yang diikuti)

KOMUNITAS PERIA KRISTEN DAN DUTA PERLINDUNGAN ANAK DI KUTAI BARAT

DESCRIBE THE ORGANIZATION STRUCTURE WHICH SHOWS YOUR POSITION ON LATEST


POSITION Gambarkan struktur organisasi yang memperlihatkan posisi anda di pekerjaan yang terakhir

General Manager

Kepala Teknik Tambang

Mgr Finance Mgr Production Mgr Plant Mgr HSE

Spv. HR/GA Spv. HR/GA Spv. HR/GA Supv. Safety


Supv. Enviro

Effective Date: 01 July 2011


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PUT AN X IN THE CORRECT RESPONSE BOX YES NO REMARKS


Berikan tanda X pada kotak jawaban yang tepat Ya Tidak Alasan

HAVE YOU PREVIOUSLY APPLIED TO OUR COMPANY/GROUP?


IF SO, WHEN & WHAT POSITION?
Apakah anda pernah melamar di Group/Perusahaan ini sebelumnya? X
Bilamana dan sebagai apa?

ARE YOU ALSO APPLYING TO OTHER COMPANIES?


IF YES, PLEASE MENTION WHAT COMPANIES AND POSITION APPLIED? X
Selain disini di perusahaan mana lagi Anda melamar waktu ini?
Sebagai apa?

ARE YOU UNDER ANY CONTRACT AGREEMENT WITH OTHER COMPANIES? X


Apakah Anda terikat kontrak dengan perusahaan tempat kerja Anda saat ini?

DO YOU HAVE ANY PART TIME JOB?


SPECIFY THE NAME OF THE COMPANY AND POSITION HELD? X
Apakah Anda mempunyai pekerjaan sampingan/part time?
Dimana dan sebagai apa?

DO YOU HAVE ANY OBJECTIONS IF WE CONTACT YOUR PREVIOUS


EMPLOYER FOR REFERENCE CHECKING? X
Apakah Anda berkeberatan bila kami minta referensi pada perusahaan tempat
Anda pernah bekerja?

DO YOU HAVE ACQUAINTANCE(S) OR RELATIVE(S) EMPLOYED BY OUR


M. ARDIANTO, HERA FAJARIAWAN
SUKENDAR, PRAYONO, YUDO, BUANG
COMPANY/GROUP? PLEASE,MENTION NAME AND YOUR RELATIONSHIP X LUANG, DLL
Apakah Anda mempunyai teman/sanak saudara yang bekerja di Group/
perusahaan ini? Sebutkan nama dan hubungan Anda.

WHAT SERIOUS ILLNESS/SURGERIES/ACCIDENTS HAVE YOU EVER HAD?


WHEN YOU HAVE HAD IT & WHAT KIND? X
Apakah Anda pernah menderita sakit keras/kronis/kecelakaan berat/operasi?
Bilamana dan macam apa jelaskan!

HAVE YOU EVER UNDERGONE ANY PSYCHOLOGICAL TESTS BEFORE?


IF SO, WHEN AND FOR WHAT PURPOSE?
2005 UNTUK MASUK
Apakah Anda pernah menjalani pemeriksaan psikologi,psikotes? x PT. TRUBAINDO COAL MINING
Bilamana, dimana dan untuk tujuan apa?

HAVE YOU EVER BEEN INVOLVED IN ANY ADMINISTRATIVE, CIVIL, OR


CRIMINAL CASE? X
Apakah Anda pernah berurusan dengan polisi karena tindakan kejahatan?

IF ACCEPTED, DO YOU HAVE ANY OBJECTIONS TO OUT OF


JAKARTA ASSIGMENT? X
Bila diterima, apakah Anda keberatan untuk ditempatkan di luar Jakarta?

IF ACCEPTED, DO YOU AGREE TO BE LOCATED ANYWHERE IN INDONESIA?


PLEASE MENTION THE PREFERRED CITIES OR REGIONS. X KUTAI BARAT
Bila diterima, bersediakah Anda ditempatkan di seluruh daerah di Indonesia?
Sebutkan nama kota dan daerahnya!

DESCRIBE ANY KIND OF JOBS THAT ARE IN LINE WITH CAREER PLAN
Macam pekerjaan/jabatan apakah yang sesuai dengan cita-cita Anda?

DESCRIBE ANY KIND OF JOBS THAT YOU DO NOT LIKE BEKERJA DG TIM
Macam pekerjaan bagaimana yang Anda tidak sukai?

IF ACCEPTED, WHEN CAN YOU START WORKING? SECEPATNYA


Bila diterima kapankah Anda dapat mulai bekerja?

HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE IS TRUE. AND IF UNDER ANY CIRCUMSTANCES ANY
MISREPRESENTATION OR OMISSION OF INFORMATION IS FOUND, I UNDERSTAND THAT I SHALL FULLY BE HELD
RESPONSIBLE. Dengan ini saya nyatakan bahwa keterangan yang saya berikan di atas benar isinya. Bilamana ternyata terdapat
ketidakbenaran, saya bertanggung jawab penuh atas segala akibatnya.

20

( ..)
APPLICANT
Pelamar

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TCM-F-HR-003

Name : Position :
Nama Posisi

Please write down your salary based on Employment History :


Mohon tuliskan gaji anda berdasarkan Riwayat Pekerjaan :

A. Name of Firm Monthly Gross Salary


Nama Perusahaan Gaji Kotor per bulan

Start
Awal

End
Akhir

B. Name of Firm Monthly Gross Salary


Nama Perusahaan Gaji Kotor per bulan

Start
Awal

End
Akhir

C. Name of Firm Monthly Gross Salary


Nama Perusahaan Gaji Kotor per bulan

Start
Awal

End
Akhir

D. Name of Firm Monthly Gross Salary


Nama Perusahaan Gaji Kotor per bulan

Start
Awal

End
Akhir

E. Name of Firm Monthly Gross Salary


Nama Perusahaan Gaji Kotor per bulan

Start
Awal

End
Akhir

Please State Your Current Monthly Income And Facilities :


Berapa besarkah penghasilan Anda sebulan dan fasilitas apa saja yang anda peroleh saat ini :

If Accepted, State Salary And Fasilities Desired :


Bila diterima, Berapakah gaji dan fasilitas yang Anda harapkan :

Signature :
Paraf
qkx

Effective Date: 01 July 2011


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