Doc. No. F.HRD.RCD.

029
FORMULIR
Issued Date 27-Feb-17

PT WARUNA NUSA SENTANA DATA PRIBADI CALON KARYAWAN Rev. No/Date 00/--

Strictly Confidential

Posisi yang dilamar Occupational Health & Safety

(Position applied)
Photo

Info lowongan kerja (job vacancy information)

Jobstreet JobsDB Linkedin Instagram Lainnya/others : _______________

I IDENTITAS PRIBADI - PERSONAL IDENTITY

Nama Lengkap (Full Name) Agil Laksitha Irsyad
Jenis Kelamin (Sex) Laki - Laki
Tempat & Tanggal Lahir (Place & Date of Birth) Jakarta, 15 April 1995
Agama (Religion) Islam
Kewarganegaraan (Nationality) Indonesia
Suku (Ethnic) Jawa
Hoby (Hobby ) Olahraga
Status Perkawinan (Marital Status) Belum Menikah (Single)
Menikah (Married) Tahun (Since) Agustus 2020
Janda / Duda (Widow / Widower) Tahun (Since)

No. KTP/Passport (Identity Number) 3201-0215-0495-0007

Alamat Sesuai KTP (Address Based Identity Card) Komplek TWP TNI AL, Blok CC 15/6, Ciangsana, Gunungputri, Kab. Bogor
Kode Pos (Postal Code) : 16968
Alamat Saat Ini (Current Address) Komplek TWP TNI AL, Blok CC 15/6, Ciangsana, Gunungputri, Kab. Bogor
Kode Pos (Postal Code) : 16968
Status Tempat Tinggal (Residential Status) Own House Rented House Parents Others

Handphone / Telp. Rumah (Mobile/Home) +6281-3148-666-46 / 84934304

Email (E-Mail) agillaksitha@yahoo.com

Sosial Media (Social Media Account) agillaksitha_ (Instagram)

Surat Izin Mengemudi (Driver License) SIM A SIM B1 SIM B2 SIM C
Nomor SIM (license number) : 9504-1325-0043

II LATAR BELAKANG KELUARGA - FAMILY BACKGROUND

1 Susunan Anggota Keluarga (Family Member) , Termasuk Anda (Including You)

Anggota Keluarga Name Lengkap Usia Pekerjaan

Pendidikan (Education)
(Family Member ) (Full Name) (Age) (Occupation)

Ayah (Father ) Suwarjianta TNI AL

53 Tahun Strata I

Ibu (Mother ) Sri Hariyati Pegawai Bank

50 Tahun Strata I
Anak Pertama
Agil Laksitha Irsyad Pegawai Swasta
(1st Children ) 26 Tahun Strata I
Anak Kedua
Nindi Laksmitha Pegawai Bank
(2nd Children ) 25 Tahun Strata I
Anak Ketiga
Anom Laksmana STTD/Mahasiwa/Taruna
(3rd Children ) 20 Tahun Taruna/Mahasiswa
Anak Keempat
(4th Children )
2 Isilah kolom ini bila sudah menikah (Fill this collumns if you are married)
Anggota Keluarga Nama Lengkap Usia Pendidikan Pekerjaan
(Family Member ) (Full Name) (Age) (Education) (Occupation)

Suami/Istri (husband/wife ) Adelya Intan Saputri 24 Tahun SMK Mengurus Rumah Tangga

Anak Pertama
(1st Children )
Anak Kedua
(2nd Children )
Anak Ketiga
(3rd Children )

III PENDIDIKAN DAN KETERAMPILAN - EDUCATION AND SKILL

1 Pendidikan Formal (Formal Education )
Tingkat Nama Institusi Nilai Akhir Masa Pendidikan
Jurusan (Major)
(Level ) (Institutions Name ) (Grade) (Education Period)
SMA/SMK
SMK Yadika 11 Bekasi SMA 87,5 3 Tahun
(High School )

Diploma Akademi Migas Balongan T.Perminyakan 2,89 3 Tahun

S1 (Degree ) Universitas Mercubuana T.Industri 3,14 2 Tahun

S2 (Master )

2 Pendidikan Non Formal (Non Formal Education )

Nama Pelatihan/Kursus Nama Institusi
No Sertifikat (Yes/No)
(Training Name ) (Institutions Name)
1 Ahli K3 Umum Kemnaker RI Available

2 Iso 9001:2015,Iso 45001:2018, etc MAP Available

3 Basic First Aid Lv 1 Pro Emergency Available

3 Organisasi yang pernah Anda ikuti (Organizations you have Joined )

Nama Organisasi
No Jenis Organisasi Periode Jabatan
(Organizations Name )
1 Perbakin Ohlaraga Menembak 2012 Atlit

2 PBVSI Sub Jakarta Timur Bola Voli 2009 Atlit

4 Penguasaan Bahasa Asing (Non Mother Tongue Language Ability) Poor / Fair / Good
Bahasa Menulis Membaca Berbicara
No
(Languages) (Writing) (Reading) (Speaking)
1 Bahasa Inggris Medium Medium Medium
2
3

5 Penguasaan Keterampilan Tambahan (Skill Abilities) *Level 1 - 4 menunjukkan rendah ke tinggi

Tingkat Penguasaan (level) Sertifikat
No Keterampilan (Abilities)
1 2 3 4 (Sertificate)
1 Ms. Office (word,excel,powerpoint,visio) X

3
IV RIWAYAT PEKERJAAN - WORK HISTORICAL
1 Isi pengalaman kerja dimulai dari pekerjaan yang terbaru (Work experience start from the current job)
Masa Kerja (Work Period) : Januari 21 s/d Present
Name Perusahaan (Company Name) PT. Grogol Sarana Transjaya (Grogol Group)
Alamat Perusahaan (Company Address) Surimulia Warehouse Complex A-1 Jl. Margomulyo 44. Surabaya – East Java
Bidang Usaha (Business Line) Alat Berat, Transportasi, Pelayaran, Bongkar Muat, Trucking, Logistik
Jabatan (Current Position) HSE Supervisor
Pelaporan Pekerjaan (Report Directly) Direct to Director
Total Karyawan (Total number of employees) 300+
Jumlah Bawahan (Number of Sub-Ordinates) N/A
Deskripsi Pekerjaan (Job Description) Set up SMK3L base on ISO 45001 : 2018, Inspection to site, and etc.

Alasan Keluar (Reason for leaving) undisciplined payroll since start joining (20 days delay)
Gaji Saat Ini (Actual Salary) IDR 7,000,000

Masa Kerja (Work Period) : Feb-20 s/d Des 20

Name Perusahaan (Company Name) PT. Alfa Valves Indonesia
Alamat Perusahaan (Company Address) Wanaherang, Kab. Bogor
Bidang Usaha (Business Line) Manufacture Valve, Etc
Jabatan (Current Position) HSE & GA
Pelaporan Pekerjaan (Report Directly) Direct to Operational Director
Total Karyawan (Total number of employees) 53
Jumlah Bawahan (Number of Sub-Ordinates) 12 (Admin GA Staff 1, Security 6, OB 3, Gardener 2)
Deskripsi Pekerjaan (Job Description) Set up SMK3L Made plan and GA and Security subcoordinate activity
OHS Implementation, Audit, Inspection environment, CSMS etc

Alasan Keluar (Reason for leaving) Career Development Level Up

Gaji Saat Ini (Actual Salary) 5,000,000

Masa Kerja (Work Period) : Nov-18 s/d Feb-20

Name Perusahaan (Company Name) PT. Hyundai Elevator Indonesia
Alamat Perusahaan (Company Address) Petojo Selatan, Tanah Abang, Jakarta Pusat
Bidang Usaha (Business Line) Construction, Maintenance and Service Elevator Escalator
Jabatan (Current Position) EHS Staff
Pelaporan Pekerjaan (Report Directly) EHS Team Leader
Total Karyawan (Total number of employees) 214
Jumlah Bawahan (Number of Sub-Ordinates) N/A
Deskripsi Pekerjaan (Job Description) Report activity based on EHS Form to EHS Team Leader

Alasan Keluar (Reason for leaving) Career Development Level Up

Gaji Saat Ini (Actual Salary) 4.500.000

Gaji yang diharapkan (Expectation Salary) 8,000,000 (Negotiable)

2 Prestasi yang pernah dicapai selama pendidikan/bekerja (achievement & accomplishment in education or work)?
Zero Accident, passed on ISO Certified, etc

3 Jelaskan tugas dari posisi yang Anda lamar, dan alasan Anda melamar posisi ini.
(please explain about the job desc and the reason why you interested in this position)
1. Set up and Implementation OHS, base on 45001 : 2018/ ISM Code
2. Inspection item / application regulation based on SOLAS 1974, IMO, ISPS Code, Etc
VI . KETERANGAN LAINNYA (OTHER INFORMATION )
Apakah Anda pernah menderita sakit berat hingga dirawat di rumah sakit (Have you ever been hospitalized or seriously ill in long time period)?
1

Tidak / No Ya / Yes Jelaskan (please explain ) _________________________________________

2. Apakah Anda pernah terlibat/menjadi terdakwa dalam tindak pidana/perdata? (Do you ever have involved in crime/civil issue) ?

Tidak / No Ya / Yes Jelaskan (please explain ) _________________________________________

3. Apakah Anda pernah bergabung di Waruna Group? (Do you ever worked in Waruna Group?)
Posisi/Lokasi (Position/Location) __________________________
Tidak / No Ya / Yes Periode (Period) ____________________________________

4. Apakah Anda sedang proses seleksi di perusahaan lain? Are you currently applying and being processed at another company?
Jelaskan (please explain)
Tidak / No Ya / Yes

5 Sebutkan 3 kenalan mis. mantan atasan (tidak ada hubungan keluarga) yg dapat memberikan keterangan tentang kinerja
Anda / Please attach 3 references from the people (not family member) that might give the information about you?

Nama Lengkap No. Telp Pekerjaan Nama Perusahaan

Hubungan (Relationship)
(Full Name ) (Telephone) (Occupation) (Company Name)
Rudi Halim 81291217215 QMR Alfa Valves Supervise
Tyo Wahyudi 81298262602 EHS Team Leader Mass Rapid Transit Jakarta Co-Worker

6. Referensi keluarga yang dapat dihubungi ketika keadaan darurat (Family member that available to contact in emergency )?
Nama (Name) No.HP (Phone Number) Hubungan (relationship) Alamat
Adelya Intan S 82122337792 Wife Idem

7 Jelaskan faktor yang membuat anda bertahan/nyaman di suatu perusahaan? (Explain what was the most important thing that retain you in a
company?)

Facilities, etc
Hal apa yang paling membuat Anda dapat meningkatkan produktivitas kerja? (What is the most important thing that can increase your work
9 productivity?)

Bonus, Award, Etc

Urutkan prioritas dari daftar motivasi bergabung dengan Waruna Group dibawah ini. (Please arrange from 1 to 6 the
10
motivation to join Waruna Group on below lists).

Lokasi Kerja (Work Location) Tantangan/variasi pekerjaan (Challenge / task variation)

Jenjang Karir/Status Karyawan (Career Path/employee

Lingkungan Kerja (Social Working Environment)
status)

Pengembangan Diri (Self-Actualization) Salary & Benefit (Compensation & Benefit)

11 . Jika DITERIMA, kapan Anda dapat mulai bekerja (if you are ACCEPTED, when will you able to join)?
Less than one month notice.

Dengan ini saya menjamin bahwa jawaban yang saya berikan atas pertanyaan – pertanyaan di atas adalah BENAR adanya dan saya memberikan
kuasa kepada PT. Waruna Nusa Sentana untuk mencari keterangan mengenai diri saya, apabila dikemudian hari ternyata Saya memberikan
keterangan palsu, maka Saya bersedia diambil tindakan sesuai dengan peraturan yang berlaku.
(Hereby I certify that all of the statements above are CORRECT and give the authorization to PT. Waruna Nusa Sentana to make any inquiries
concerning my self, If one day I proved declare the wrong statements of mine, I will accept the criminal procedures as my responsibility).

Jakarta, 26 May 2021

Agil Laksitha Irsyad