CONFIDENTIAL

CBSA GROUP OF COMPANIES

EMPLOYMENT APPLICATION FORM

INSTRUCTIONS
1. 2. 3. 4. 5.

The applicant is WARNED that any falsification in this application will result in rejection of the application or if not detected until after appointment an instant dismissal of the applicant. All information provided will be treated as strictly confidential. Please attach copies of certificate / testimonials where applicable. Do not leave any item blank, please write NA if not applicable. Please tick () in appropriate box.

POSITION APPLIED

REFERENCE SOURCE
Advertisement (Newspaper) Advertisement (Online) Walk-In CBSA Staff (Name) Others

A. PERSONAL PARTICULARS
Full Name: Mr./Ms./Mrs. (as in NRIC) Date of Birth: Christian Name: Current Address: Gendar: Height: Name (Mandarin): (if any) Age: Weight:

CBSA Media Sdn Bhd

(formerly known as SUPER PAGES MEDIA SDN BHD) (738550-W)

CBSA Online Sdn Bhd

(formerly known as INFODATA MEDIA SDN BHD) (619214-M)

CBSA International Sdn Bhd

(formerly known as INFODATA MEDIA SDN BHD) (619214-M)

CBSA PanCommerce Sdn Bhd

(formerly known as INFODATA MEDIA SDN BHD) (619214-M)

Telephone (Home): IC No (New & Old): Religion: Driving License:

(Handphone):

(Office):
1, Jalan PJS 11/8, Bandar Sunway, 46150 Petaling Jaya, Selangor Darul Ehsan, Malaysia.

Email Address: Nationality: Vehicle Model & No:

Vehicle Owned:

B. FAMILY PARTICULARS Marital Status Please tick () in appropriate box.

Single Married Divorced Others (please specify) To be completed by married applicant only Name of Spouse: Nationality: Spouse Employer: Husbands Income Tax No: IC No (New & Old): Occupation: Tel No:

Email: infomedia@cbsagroup.com Website: www.cbsagroup.com www.superpages.com.my Tel: (603) 5636 9999 Fax: (603) 5635 0280 BRANCH OFFICES: Penang: Tel: (604) 643 0699 Fax: (604) 642 1889 Perak: Tel: (605) 549 8048 Fax: (605) 549 7801 Pahang: Tel: (609) 567 0988 Fax: (609) 568 5988 N. SEMBILAN: Tel: (606) 633 7275 Fax: (606) 633 7275 Melaka: Tel: (606) 283 9195 Fax: (606) 283 9041

Childrens Name (If any)

Name: Name: Name: Name: Name: Gender: Gender: Gender: Gender: Gender: Date of Birth: Date of Birth: Date of Birth: Date of Birth: Date of Birth:

Johor: Tel: (607) 357 4511 Fax: (607) 354 9524 SABAH: Tel: (088) 219 199 Fax: (088) 224 199 SARAWAK: Tel: (082) 415 263 Fax: (082) 415 262 a Company l www.cbsagroup.com

Family Members
Please list your brother(s) and sister(s) in order of age and their occupation (1): (2): (3): (4): (5): (6): (7): Name Relationship Father Mother Age Occupation & Employer

C. EDUCATIONAL BACKGROUND
School / University / Institute / Courses Attended Period (mm/yy) To From State / Country Qualification & Grade Obtained (attached copies of certificate)

Give details of any professional association in which you are a member and type of membership.

D. ACTIVITIES / SPORTS
(1): (2): (3): (4): (5): (6):

E. LANGUAGE / DIALECT ABILITY

Language / Dialects (mark where applicable) English Bahasa Melayu Bahasa Cina Other Poor Poor Poor Poor Spoken (Speech Proficiency) Fair Fair Fair Fair Good Good Good Good Excellent Excellent Excellent Excellent Poor Poor Poor Poor Written (Written Proficiency) Fair Fair Fair Fair Good Good Good Good Excellent Excellent Excellent Excellent

F. ADDITIONAL SKILLS (If applicable)

Computer Knowledge Software Other Skills Poor Poor Fair Fair Good Good Excellent Excellent Poor Poor Fair Fair Good Good Excellent Excellent

G. EMPLOYMENT HISTORY Give details including temporary work, if any (start with your present employment)
Employers Name & Address Type Of Industry Period (mm/yy) To From Position Held & Key Responsibilities Last Drawn Salary Reasons For Leaving

Company l www.cbsagroup.com

H. REFERENCES AND TESTIMONIALS Pls. provide 2 references for reference check (present or past employer, not family members & friend)
Name Occupation & Employer Address Tel

I. HEALTH CONDITION
a. Present state of health: b. Do you have any physical disabilities or handicap, if any (e.g. sight, hearing, speech, lameness, heart) c. Do you have any challenge illness requiring constant medication? If YES, please state d. Have you had any serious illness or accident suffered since birth, with approx. date e. To be completed by female employer only. Are you pregnant and how many week?

J. OTHER INFORMATION
a. Have you been convicted for any prosecuted? (e.g. road violation, court cases) If yes, please indicate case and when. b. Have you been terminated by your former employment and when? c. Were you previously employed by CBSA Group? d. If YES, state position held, date, duration & reasons for leaving e. Do you have any relative of friends employed by CBSA Group? If YES, state their name and the nature of relationship f. Are you serving any bond with any parties? If YES, please state

K. PRESENT REMUNERATION
Current Basic Salary: Commission: Expected Salary: RM___________________ /per month If engaged, when can you start work? Negotiable: Yes No Termination Notice Required: Other Incentive: Other Allowances (Please state):

DECLARATION
I certify that all of the above information is accurate. All of my certificates, documents forwarded are genuine and I have not been convicted for any criminal offences. I accept summary dismissal for any false declaration of the above facts.

Date:

Signature of Applicant:

Note: Please attach photocopies of your certificates and testimonials.

Company l www.cbsagroup.com