Personal Data

Mandatory fields are marked with red color and asterix

Advertisement Code and Job Position Name* Gender* ID No.* Place of Issue* Date of Issue (dd-mm-yyyy)* Place of Birth* Date of Birth (dd-mm-yyyy)* Religion* Nationality* ID Address* Russeno Dwi Putra Male 327512121009900004 bekasi (west java) 10 Jakarta 10 Islam - ISL Indonesia Jl Melati 2 A no 66 RT 001 / RW 022 Jatirahayu, Pondok Melati City* Postcode* Current Address* Bekasi 17414 Jl Melati 2 A no 66 RT 001 / RW 022 Jatirahayu, Pondok Melati City* Postcode* Phone Numbers Home* Office Cellular E-mail Emergency Contact* (preferably in different address ) Name Relationship Address Rusmani Bustomi Parents Jl Melati 2 A no 66 RT 001 / RW 022 Jatirahayu, Pondok Melati Phone Numbers Civil Status* Date of Marriage (dd-mm-yyyy) How were you referred to us?* Name of referral source Relationship INTERNET - Internet ad Jobstreet 96096121 Single - SG --087887415980 russenodp@rocketmail.com 8477551 Bekasi 17414 10-Sep-1990 9 2011 10-Sep-2011

HRIS Analyst

1990

Family Details
Name Relationship Day Father Mother Date of Birth Month Year Date of Birth (system use) ----------------Education / School Occupation / Employer

Spouse and Children

Name Relationship Day Date of Birth Month Year Date of Birth (system use) --------Education / School Occupation / Employer

Formal Education

Period Name of School and Location Start Senior High School Academy University Post Graduate End Degree Major Honor / Award

Informal Education / Courses / Seminar / Training

Period Name of Institution and Location Start End Subject / Topic Honor / Award

Computer Programming Languages and Operating System most proficient (Use comma as separator)

Language

Specified Other Language English Chinese, please specify: Other, please specify:

Spoken

Written

Membership of Professional, Social or Political Activities

Period (yyyy - yyyy)

Name of Organization

Type of Organization

Activities

Position

Referrees
List three persons not related to you who have known you at least one year

Name

Organization

Phone

Relationship

No. of Years Known

General
1. Have you been or are you suffering from any physical disability or disease? If Yes , please explain

2. Have you ever applied for any post with Prudential Life Assurance? If Yes , please explain

3. Have you previously been employed at this company or its subsidiaries? If Yes , please explain 4.Do you have any family relation or close friend working as a Prudential's agent or in agency office or Prudential's employee or Prudential's supplier? Name If Yes , please state the information Relationship
Work as: Prudential's agent / work in agency office / Prudential's employee / Prudential's supplier

5.Do you have any family relation or close friend working in another Life Insurance and or in Reassurance? Name If Yes , please state the information Relationship
Company

6. Have you ever been dismissed or suspended by any previous employer? If Yes , please explain

7. Have you ever been charged or convicted in any Court of Law? If Yes , please explain

8. Are you willing to work overtime? If No , please explain

9. Are you willing to travel? If No , please explain

10. Are you willing to assigned outside your point of hire? If No , please explain

Employment History
Start with present employment, including temporary work and vocational training

Present Employment
Employer Nature of Business Address: Starting Salary: Final Salary: Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

Previous Employment
Employer Nature of Business Address: Starting Salary: Final Salary: Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

Employer Nature of Business Address:

Starting Salary: Final Salary:

Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

Employer Nature of Business Address:

Starting Salary: Final Salary:

Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

Employer Nature of Business Address:

Starting Salary: Final Salary:

Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

Employer Nature of Business Address:

Starting Salary: Final Salary:

Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

Employer Nature of Business Address:

Starting Salary: Final Salary:

Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

Employer Nature of Business Address:

Starting Salary: Final Salary:

Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: From: To:

Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving:

Employer Nature of Business Address:

Starting Salary: Final Salary:

Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

Employer Nature of Business Address:

Starting Salary: Final Salary:

Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

Employer Nature of Business Address:

Starting Salary: Final Salary:

Rp. Rp.

Position Title and Work Performed:

Phone Number: Employment Dates: Supervisor's Name and Title: May we contact? If No, please explain Reason for Leaving: From: To:

DETAILS OF CURRENT EMPLOYER A. Organization Chart

B. Please Give Details of Your Salary and Benefits

Monthly Basic Salary: Eligible for Overtime: If Yes, monthly average: Monthly Allowances: Meal: Transportation: Handphone:

Rp.

Pension Funds (on top of Jamsostek): Employee Contribution Rp. or Company Contribution Rp. or Company car provided If yes, car type: Operational cost: Driver provided: Year: Rp. % from monthly salary % from monthly salary

Rp.

Rp. Rp. Rp.

Others (please specify): Rp. Rp. Rp. Annual Bonnus: THR: Variable Bonus: Rp. Rp. or Medical Benefits: Outpatient: In-patient: Rp. Rp. Rp. Life & Disability Coverage: Rp. or x monthly salary per year (Room and Board) Annual Limit % from annual salary

Loan facilities provided by the Employer: Housing Max limit (Rp.) Interest per year (%) Repayment period (year) Annual Leave: Entitlement: Additional Leave: Other Benefits, please explain: days days, after years of service Car Personal

Commencement and Salary Expectation

1. If you are offered employment with us, when can you start work? 2. What is your salary expectations if you are offered employment with us? Rp. ---

Declaration
I authorize the investigation of all information provided by me in this Application for Employment Form except those pertaining to my current employment. I understand that as part of recruitment process, PT Prudential Life Assurance will ask me to submit copies of reference letter of my current and previous employers, copies of relevant certificates, last salary statement and check my references. I also understand that a misrepresentation or ommission of facts called for herein will be sufficient cause for cancellation of consideration for employment or dismissal from the Prudential's service if I have been employed.

Russeno Dwi Putra Date (dd-mm-yyyy) Name