Employee Application Form

NO: _______________________

The following information will help us to assess your employment opportunity with ASTON INN MATARAM under Archipelago
International (hereinafter called the “Employer”). All portions of this application pertaining to you must be completed. We
appreciate the time you spend completing this application form.

Position applied for : Accounting (Account Payable)

Other position (s) you would like to be considered for : _________________________________________________
Salary Expectation :
Date Available to start :

PERSONAL DATA
Full Name : Date of Birth :
Address :

City : Post Code :

Telephone : (Residence)
Telephone : (Office) -
I.D Card Number : Date of Expiry : -
Marital Status : Hobby :
Height / Weight : Blood Group : -
Distinguishing Marks

EDUCATION AND TRAINING

Name and address of school, From Date To Date Major Course or Study Decree of Certificate
University or other training
institution

RECORD OF PREVIOUS EMPLOYMENT

1. Company Name : _____________________________________________________________________

Position : _____________________________________________________________________
Period : From ______________________ To _______________________________________
Address : _____________________________________________________________________
Telephone : _____________________________________________________________________
Nature of Business : _____________________ Supervisor’s Name : _______________________________
Duties : _____________________________________________________________________

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 Employee Application Form
Last salary : Rp __________________________________________________________________
Reason for leaving : _____________________________________________________________________

2. Company Name : _____________________________________________________________________

Position : _____________________________________________________________________
Period : From ______________________ To _______________________________________
Address : _____________________________________________________________________
Telephone : _____________________________________________________________________
Nature of Business : _____________________ Supervisor’s Name : _______________________________
Duties : _____________________________________________________________________
Last salary : Rp __________________________________________________________________
Reason for leaving : _____________________________________________________________________

3. Company Name : _____________________________________________________________________

Position : _____________________________________________________________________
Period : From ______________________ To _______________________________________
Address : _____________________________________________________________________
Telephone : _____________________________________________________________________
Nature of Business : _____________________ Supervisor’s Name : _______________________________
Duties : _____________________________________________________________________
Last salary : Rp __________________________________________________________________
Reason for leaving : _____________________________________________________________________

REFERENCES (Non – Relatives)

1. Name : ____________________ Telephone Number : ________________________

Occupation : ____________________ Years known : _____________________________
Address : _____________________________________________________________________

2. Name : ____________________ Telephone Number : ________________________

Occupation : ____________________ Years known : _____________________________
Address : _____________________________________________________________________

3. Name : ____________________ Telephone Number : ________________________

Occupation : ____________________ Years known : _____________________________
Address : _____________________________________________________________________

4. Name : ____________________ Telephone Number : ________________________

Occupation : ____________________ Years known : _____________________________
Address : _____________________________________________________________________

LANGUAGE PROFICIENCY
Language Skill ( Language, Spoken)
Language Speaking Reading Writing
English Poor Good Excellent Poor Good Excellent Poor Good Excellent
Mandarin Poor Good Excellent Poor Good Excellent Poor Good Excellent
Others Poor Good Excellent Poor Good Excellent Poor Good Excellent

FAMILY RECORD
Father’s Name : Age : Occupation :

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 Employee Application Form
Mother’s Name : Age : Occupation :
Permanent Address :

____________________________ City : Telephone :

Husband / Wife’s Name : _______________
Children :
1. Name : _______________________
2. Name : _______________________
3. Name : _______________________
Birth of Date : ____________Occupation : _________________________
Birth of Date : _______ Male ______ Female _____
Birth of Date : _______ Male ______ Female _____
Birth of Date : _______ Male ______ Female _____

GENERAL INFORMATION

Are you presently employed ? ______________ Yes ______√________ No ______________________________

Have you ever been discharged from employment ? If yes, Please explain ____(No)_________________________________

Have you any objection to our contacting your previous employers ? _________ Yes ______ No ______√______________
Have you had any serious illnesses, injuries or operations within the last (5) years? If so, please describe (No)

Have you ever suffered from any of the following illnesses?

Tuberculosis Yes ___ No ___ Heart Disease Yes ___ No ___
Hypertension Yes ___ No ___ Diabetes Yes ___ No ___
Venereal Disease Yes ___ No ___ Epilepsy Yes ___ No ___
Hepatitis Yes ___ No ___ HIV / AIDS Virus Yes ___ No ___

Do you have any immediate family members, i.e. husband, wife, parents, child, brother, sister, working within the company ?
Yes ___ No _√__
If yes, who ?
(1) __________________________________________________________________________________________
(2) __________________________________________________________________________________________
(3) __________________________________________________________________________________________

DECLARATION
I certify that all statements made on this application are true and complete to the best of my knowledge. I understand
that misrepresentation or omission when discovered, will subject me to discharge and I hereby authorize any
investigation relating to my work experience, education or reputation for the purpose of my application for employment.

Applicant’s Signature ________________________ Date ___________________________________

INTERVIEW ASSESSMENT
CODE : 1. Excellent 2. Very Good 3. Good 4. Need Improvement 5. Poor

Subject 1st 2nd 3rd

Interview Comment Interview Comment Interview Comment
Appearance
Verbal Skill
Language Skill
Interpersonal Skills

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 Employee Application Form
Technical Skills
Professional Skills
Initiative Leader Ability
Motivation
Stability
Co-Operative Attitude
Reliability

Interviewer’s Name
Date
Overall Comment

For Human Resources Department Only

Position : __________________________________
Starting Date : __________________________________
Level : __________________________________
 Basic Salary : __________________________________
 Transportation Allowance : __________________________________
 Service Charge : __________________________________
 Service Charge Point : __________________________________
 Housing Allowance : __________________________________
 Others : __________________________________
 Gross Salary : __________________________________

REFERENCE CHECKING
1. Name / Company : ___________________________ Date : _______ Comment : __________________

2. Name / Company : ___________________________ Date : _______ Comment : __________________

APPROVED FOR HIRE

Department Head Date : ____________________________________________

Human Resources Manager / Director Date : ____________________________________________

General Manager Date : ____________________________________________

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