PT.

KARTIKA PERKASA NUSANTARA

JL. DEWI SARTIKA NO. 08 RT.013 RW.004 KEL. CILILITAN KEC. KRAMAT JATI JAKARTA TIMUR
E-mail: pt.kartikaperkasaind@gmail.com, Telp: 021-8098211, HP: 081297960022

FORM PENGAJUAN UNTUK PENGAMBILAN

KTA & S. GADA PRATAMA/KTA & S. GADA MADYA/ SURAT PENGALAMAN KERJA

Nama : ………………………………………………………………………….
Tempat / Tgl. Lahir : ………………………………………………………………………….
Agama : ………………………………………………………………………….
No. KTP / NRG : ………………………………………………………………………….
Alamat sesuai tempat tinggal : ………………………………………………………………………….
………………………………………………………………………….
………………………………………………………………………….
No. Tlp / HP : ………………………………………………………………………….
Dari Unit Kerja : …………………………………………………………………………
Masa Kerja (tgl/bln/thn) : …………………………………………………………………………
Keperluan : …………………………………………………………………………
Lampiran Persyaratan : - Copy SPKWT (Khusus Pengambilan Paklaring)
- CV (Daftar Riwayat Hidup)
- Copy KTP Legalisir
- Copy Ijazah Terakhir (SLTA/D3/S1) Legalisir
- Copy NPWP berwarna
- Copy BPJS Ketenagakerjaan & Kesehatan
- Copy SKCK (yang masih aktif dan berlaku) Legalisir
- Print Buku Tabungan / Rekening Koran potongan gaji.

Persetujuan Manager HRD …………………. Disetujui / Tidak disetujui

Persetujuan Admin Keuangan …………………. Sudah lunas / Belum lunas

Jakarta, 20......

( ……………………………………………….. )
Pemohon
 Pas Foto
Latar Merah
Berpakaian
Security

FORM DAFTAR RIWAYAT HIDUP 3x4

DATA PRIBADI

Nama Lengkap : ..........................................................................................................................

Tempat, Tanggal Lahir : ..........................................................................................................................
NIK : .............................................................................................................................
Jenis Kelamin : .............................................................................................................................
Kewarganegaraan :
Agama : .............................................................................................................................
Status : .............................................................................................................................
Alamat sesuai KTP :
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Alamat Domisili : .............................................................................................................................
.............................................................................................................................
No. Telpon/HP : ............................................................................................................................
Email : ............................................................................................................................

PENDIDIKAN FORMAL
SD ...................................................... : ............................................................................................................................
SMP .................................................. : ............................................................................................................................
SMU .................................................. : ............................................................................................................................
PENDIDIKAN INFORMAL
1. ......................................................................................................................................................................................
2. ......................................................................................................................................................................................
3. ......................................................................................................................................................................................
4. ......................................................................................................................................................................................

RIWAYAT PEKERJAAN
1. ......................................................................................................................................................................................
2. ......................................................................................................................................................................................
3. ......................................................................................................................................................................................
4. ......................................................................................................................................................................................
Demikian riwayat hidup ini saya buat dengan sebenarnya.

Mengetahui, Jakarta,

( Aldo Farros, S.H ) (......................................... )

Staff HRD Pemohon