FORM APLIKASI KANDIDAT KARYAWAN

(APPLICATION FORM)

Isilah Form ini dengan lengkap dan data yang benar. Isilah dengan huruf balok.
(Please fill the form completely with valid data & use the capital letter)

DATA DIRI KANDIDAT KARYAWAN (PERSONAL DATA)

Nama Lengkap (Full Name) BADRI PERMANA Nama Panggilan (Nick Name) : BADRI

Tempat / Tgl & Th. Lahir

(Place & Date of Birth) BOGOR, 10 APRIL 1996

Alamat Sekarang & Kode Pos

(Current Address) KP. COKRAK PABUARAN RT 001 RW 007, TEGAL WANGI, KEC. JASINGA KAB.
BOGOR 11670

Alamat Tetap & Kode Pos

(Permanent Address) KP. COKRAK PABUARAN RT 001 RW 007, TEGAL WANGI, KEC. JASINGA KAB.
BOGOR 11670

Telepon & HP (Phone)

085788389833
Alamat E-mail (E-mail Address)
Permanabadri10@gmail.com
Agama (Religion)
ISLAM
KTP Dikeluarkan di (Issued Place) : KABUPATEN BOGOR
Dikeluarkan Tanggal (Issued Date) : 24 – 03 - 2018
No : 3201191009960001
Habis Masa Berlaku Tgl. (Expire Date) : SEUMUR HIDUP

Kewarganegaraan
(Nationality) Blood Type : B

□ Belum menikah /single

Status Pernikahan (Marital Status)

RIWAYAT PENDIDIKAN / EDUCATIONAL BACKGROUND

JENJANG PENDIDIKAN NAMA SEKOLAH TAHUN LULUS
JURUSAN (Major)
(Level of Education) (Institution) (Graduated Year)

SD/ MI (Elementary School) SDN KOLEANG 03 2009 -

SMP/ MTs (Junior High School) SMP CAGAR BUDAYA 2012 -
SMA/ SMK/ MA (Senior High School) SMAN 1 JASINGA 2015 IPA
Diploma (Diploma) POLITEKNIK NEGERI JAKARTA 2019 TEKNIK SIPIL
Universitas (University)

Master (Master Degree)

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 DATA KELUARGA (FAMILY MEMBER)

Data Tanggungan (Dependent Data)

HUBUNGAN KELUARGA NAMA L/P TGL. LAHIR PENDIDIKAN PEKERJAAN
(Relationship) (Name) (M/F) (Place/Date of Birth) (Education) (Occupation)

Suami / Istri (Spouse)

Anak ke 1(Children)

Anak ke 2 (Children)

Anak ke 3 (Children)

Anak ke 4 (Children)

Anak ke 5 (Children)

Kontak Keadaan Darurat (Emergency Contact)

Nama (Name) : ANANI
Hubungan dengan Anda (Relationship) : SAUDARA KANDUNG
No. Telp (Phone Number) : 085693272305

Susunan keluarga , termasuk anda (please describe your familiy member include yourself)
HUBUGAN NAMA L/P TGL. LAHIR PENDIDIKAN PEKERJAAN
KELUARGA (Name) (M/F) (Place/Date of Birth) (Education) (Occupation)
(Relationship)
Ayah (Father) Ading L 20-05-1956 SD TIDAK BEKERJA
IBU RUMAH
Ibu (Mother) Roiah P 10-08-1961 SD
TANGGA
Anak kandung ke 1 IBU RUMAH
P 10-06-1982 SMP
(Siblings number 1) Siti Masitoh TANGGA
Anak kandung ke 2
(Siblings number 2)
L 09-01-1985 SD Karyawan Swasta
Junaedi Abdilah
Anak kandung ke 3
P 20-01-1989 SMP Karyawan Swasta
(Siblings number 3) Anani
Anak kandung ke 4
P 06-10-1990 SMP Karyawan Swasta
(Siblings number 4) Uum
Anak kandung ke 5
L 10-04-1996 SARJANA Karyawan Swasta
(Siblings number 5) Badri Permana
Anak kandung ke 6
(Siblings number 6)
Ami Nurcahyati P 09-11-2002 SMA PELAJAR
Anak kandung ke 7
(Siblings number 7)
Aminah Nurcahyati P 09-11-2002 SMA PELAJAR

INFORMASI REKENING BANK (BANK’S DETAILS)

Nama Pemilik Rekening (Beneficiary’s Name) : BADRI PERMANA

Nama Bank (Bank Name) : MANDIRI

Cabang Bank (Bank Address) : MANADO

No. Rekening (Account Number) : 1500015555426

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KETERANGAN LAMARAN KERJA (APPLICATION DETAILS)

Posisi yang Dilamar (Position Applied For) : LABORATORY GEOTECHNICAL/SITE ENGINEER

Lokasi Proyek (Project Location) :

Bila diterima, kapan anda dapat mulai berkerja?

(If you accepted by this company when can you start to work?) : 18 Juli 2022

KURSUS & TRAINING/TRAINING & COURSE

NAMA TRAINING TGL-BLN-TAHUN PENYELENGGARA
NO
(Training & Course) (DD-MM-Year) (Held by)
LEMBAGA SERTIFIKASI PROFESI
AHLI MUDA K3 KONTRUKSI 03-10-2019
POLITEKNIK NEGERI JAKARTA
BALAI JASA KONSTRUKSI WILAYAH III
AHLI MUDA BIDANG JASA KONTRUKSI 02-03-2019
JAKARTA
PELATIHAN MANDIRI JARAK JAUH BIDANG BALAI JASA KONSTRUKSI WILAYAH III
07-03-2019
KONSTRUKSI JAKARTA
INHOUSE TRAINNING BASICIVAL SEA SURV 27-03-2022 PT. PERUSAHAAN GAS NEGARA

BAHASA ASING YANG DIKUASAI (Baik Sekali, Baik, Cukup, Kurang)/

LANGUAGE (Excellent, Good, Satisfy, Poor)
JENIS BAHASA MENDENGAR MEMBACA BERBICARA MENULIS
NO
(Language) (Listening) (Reading) (Speaking) (Written)
ENGLISH ELEMENTARY ELEMENTARY BEGINNER ELEMENTARY

KEAHLIAN LAINNYA (OTHER SKILLS)

NO JENIS KEAHLIAN (Type of Skills) KETERANGAN (Remark)

Komunikasi
Kerja sama/Kolaborasi
Creativity

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PENGALAMAN KERJA (EMPLOYMENT HISTORY)

BULAN & TAHUN

NAMA PERUSAHAAN ALAMAT PERUSAHAN NO. TELP. NAMA KONTAK JENIS BIDANG USAHA (Bulan & Tahun) ALASAN BERHENTI
(Company’s Name) (Company’s Address) PERUSAHAAN (Contact Name) (Class of Work) (Reason of Leaving)
(Company’s Phone No.)
DARI (from) SAMPAI (to)
PLAZA PP JL. LETJEN. TB. M. NAUFAL H. KONTRUKSI 06-02-2020 30-09-2021 SELESAI KONTRAK
PT. PP (PERSERO) Tbk SIMATUPANG NO. 57 KOTA 081216530305 SDM PP MANADO
PT. SOLUSI ENERGY JAKARATA
DURI TIMUR
KEPA RT 03/RW. 13 13760-
KEC. 085785488642 BITUNG
IBU TARI SDM ENGINEERING 23-03-2022 25-06-2022 SELESAI KONTRAK
KEBON JERUK, KOTA JAKARTA
NUSANTARA SENA OIL & GAS
BARAT 11510

Gaji Terakhir Tunjangan yang Didapat

(Latest Salary) : RP. 7.000.000,. (Latest Allowance Package) : RP. 6.000.000,.
Gaji yang diharapkan Tunjangan yang diharapkan
(Expected Salary) : RP. 8.000.000,. (Expected Allowance) : RP. 5.000.000,.

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HEALTH REPORT

Have you previously suffered from any of the following conditions:

(a) Industrial dermatitis or rash of any kind caused by your employment No
(b) Noise-induced hearing loss No
(c) Heart condition of any kind No
(d) Back condition or spinal disorders No
(e) Repetitive movement injury, eg tenosynovitis No
(f) Eye condition requiring medical attention No
(g) Neurosis or nervous condition of any kind No
(h) Hernia condition of any kindYes / No
(i) Injury to arm, hand or fingers, legs, feet or toes, speech, taste or smell, lungs No
(j) Have you any physical disabilities? No
Do you have any pre-existing injury or disease that may be affected by the
work position you are applying for? No
(If this information is not disclosed you will not be entitled to workers
compensation if the nature of the job aggravates the pre-existing injury or disease)

If the answer is yes to any question, please provide details of condition or pre-existing injury or disease.

Mata saya tidak kuat saat terkena/pantulan cahaya matahari yang kuat
.......................................................................................................................................................................................................................

Are you prepared to undergo a medical examination? Yes

SAFETY
Are you prepared to wear a safety helmet? Yes
Are you prepared to wear safety boots? Yes
Will you abide by all other safety requirements and construction site regulations? Yes

I certify that the information provided by me in this application is true and I understand that false
declaration is cause for immediate dismissal.

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SIGNED: BADRI PERMANA DATE: 29/ JUNI /2022

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