No.

Pegawai
:...............................
PT EBDESK TEKNOLOGI
Lokasi kerja :...............................
Tanggal bekerja :...............................
Jabatan :...............................

II-FM-HR-01-04
FORMULIR DATA PEGAWAI

I. DATA PRIBADI

Nama Lengkap : R. Askarrofi Prabularizda Anggoro

Nama Panggilan : Askar
Alamat Tetap : Jl. Pangeran Tirtayasa, Sukabumi, Kec. Sukabumi,
Kota Bandar Lampung, Lampung Kode pos : 35122
No. Telp Rumah: ............................................... No. Handphone : 0895700195175
No. Telp Darurat : ………………………………………………(…………………….………............................)
Alamat Saat Ini : Jl. Pangeran Tirtayasa, Sukabumi, Kec. Sukabumi,
Kota Bandar Lampung, Lampung Kode pos : 35122
Email : askarrofi82@gmail.com YM :.. ...................................................
Tempat & Tanggal Lahir : Bandar Lampung, 16 Mei 2006
Jenis Kelamin :  Laki-Laki  Perempuan
Agama : Islam Golongan Darah : O
Kewarganegaraan : Indonesia
Nomor KTP : 1871041605060001
NPWP : .............................................................................................................
Nomor Jamsostek : .............................................................................................................
No Rekening : ............................................... Nama : .............……...........................
Bank : ............................................... Cabang : .............……...........................
Status Pernikahan :  Belum menikah  Menikah (tanggal: ............................)
Nama Pasangan : .............................................................................................................
Tempat / Tgl. Lahir : ............................................... Golongan Darah : ……...........................
Pendidikan : ............................................... Pekerjaan : ……...........................
Jenis
Nama Anak Tempat & Tanggal Lahir Pendidikan
Kelamin
 Nama Orang Tua :
1. R. Budi Wahyono Tempat / Tgl. Lahir : Tanjung Karang, 26 April 1977
2. Sulastri Tempat / Tgl. Lahir : Panjang, 27 Mei 1975
Alamat : Jl. Tanjung Pura No. 112 LK 1
No. Telp. : 082184792563

Nama Mertua :
1. ………………………………………………… .Tempat / Tgl. Lahir : ………………………………………..
2. ………………………………………………… Tempat / Tgl. Lahir : ………………………………………..
Alamat : …………………………………………………………………………………….
No. Telp. : …………………………………………………………………………………….

II. PENDIDIKAN
A. Pendidikan Formal
Periode
Jenjang Universitas Jurusan IPK
Dari Sampai
S2
S1
D3

Periode
Jenjang Sekolah Kota Jurusan Score
Dari Sampai
Bandar Rekayasa
SMU SMK Negeri 4 Lampung Perangkat
Lunak
Bandar
SLTP SMP Negeri 25
Lampung
Bandar
SD SD Negeri 1 Karang Maritim
Lampung

B. Pendidikan Informal
Periode
Training/Kursus/Sertifikasi Lokasi Penjelasan Training Yang Diikuti
Dari Dari

C. Penguasaan Bahasa Asing

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 Bahasa Verbal Tulisan Sertifikasi (Jika Ada) Score

D. Penguasaan Bahasa Pemrograman dan Data Base

Bahasa Pemrograman & Data Base Score

Basic / Intermediate / Expert
Basic / Intermediate / Expert
Basic / Intermediate / Expert
Basic / Intermediate / Expert
Basic / Intermediate / Expert
Basic / Intermediate / Expert
Basic / Intermediate / Expert
Basic / Intermediate / Expert
Basic / Intermediate / Expert

IV. PENGALAMAN KERJA

Sebutkan hanya pekerjaan tetap Saudara/i (mulai dari jabatan terakhir, jika tidak mencukupi
lembaran ini dapat diperbanyak dan dilampirkan).

1. Nama perusahaan
: ............................................................................................
.....................
Alamat perusahaan : .................................................................................................................
Masa kerja : .................................................................................................................
Bidang Usaha : .................................................................................................................
Jabatan : .................................................................................................................
Atasan langsung : .................................................................................................................
Gaji terakhir : .................................................................................................................
Tugas dan tanggung jawab Saudara :
1. ................................................................................................................................
2. ................................................................................................................................
3. ................................................................................................................................
Alasan keluar dari perusahaan :
…………………………………………………………...................................................................................
…………………………………………………………...................................................................................
…………………………………………………………...................................................................................

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2. Nama perusahaan
: ............................................................................................
.....................
Alamat perusahaan : .................................................................................................................
Masa kerja : .................................................................................................................
Bidang Usaha : .................................................................................................................
Jabatan : .................................................................................................................
Atasan langsung : .................................................................................................................
Gaji terakhir : .................................................................................................................
Tugas dan tanggung jawab Saudara :
1. ................................................................................................................................
2. ................................................................................................................................
3. ................................................................................................................................
Alasan keluar dari perusahaan :
…………………………………………………………...................................................................................
…………………………………………………………...................................................................................
…………………………………………………………...................................................................................

3. Nama perusahaan
: ............................................................................................
.....................
Alamat perusahaan : .................................................................................................................
Masa kerja : .................................................................................................................
Bidang Usaha : .................................................................................................................
Jabatan : .................................................................................................................
Atasan langsung : .................................................................................................................
Gaji terakhir : .................................................................................................................
Tugas dan tanggung jawab Saudara :
1. ................................................................................................................................
2. ................................................................................................................................
3. ................................................................................................................................
Alasan keluar dari perusahaan :
…………………………………………………………...................................................................................
…………………………………………………………...................................................................................

Page 4 of 5
 …………………………………………………………................................................................................
.
Demikian keterangan tersebut di atas saya buat dengan sebenarnya dan penuh kesadaran. Saya
bersedia bertanggung jawab akan segala akibatnya bila dikemudian hari keterangan yang saya
berikan tersebut ternyata tidak benar.

………….…….., …………………….………

(……………………………………………..)

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