No:

APPLICATION FORM l.l ate

scl:d

Applied Division: Employment Status:

Assu rance A d vl sorv CBS - Supporl Permanent lnternshio

Applied Position: When can you start?

Curr€nt ACdress

cjty P.stai Code Ccuntr y

contacl ,r,,io'r:ie ohore Hcme

tilaii Address ofiice

Where io you live ? cv/n hor ts! rerled hcus€ bo3rdi.q loilse rviih paienii

Permanent Addre55
(b.s?t ea lD c{J / KTP / Pdrportl

city Postal Cqde ccurtry

ldentiflcaticn Card No. (KTPlPasscoit')

') a.pii€d lor.xratiate eFploree

Sex (t1 / F) Age ve:15 o;d

Date of Birth Place of Birth

Citizenship Reiiqio*

Civii Status: Si,rgle Yli.ic\.red Seo.rated

No. of Children No, of Dependents

Senior High School

(SM U)

Academy

University

Postgraduate / Advance Studies

Others Courses

Computer skills

English skills Excellenl

other lanquage
Low Excellent

Where did you hear about EY Career Website EY Campus Hiring

our job vacancy?
Application lD Location

Job Advertlsemenl others

lf so, please specify lf so, please specify

ApplEabn Form - ry Recruihent- 04/16

Have you ever been dissmissed or suspended by your previous employers ? lf so, siale date

by which company and the case

Give names and addresses of your familV background

Give names and addresses of person/ contact number, preferably lhose in business or profession, who have known you for at least three years
(Do not give names of relatives)

Are you related to any parlner or employee of this Firm ? if so, to whom?

Name referral in our employ

\ /ere you involved in any administrative, civil or criminal case? if so, please specify

Have you taken our entrance test before? lf so, when date/year

Nlinimum monthly salary acceptable (cross) Rp

Appl.ahn Form - EY Be.rutuenr- 04/]6

F
t

EY
Building a better
workinq world

I certify that the printed inlormation on this form or any supplements, and supported documents to support this form is complete and accurate

I hereby authorize EY entities to perform employment reaerence ch4ks on my previous employment, verify academic checking, and conduct full background chsks including
personal references This is not limited to overseas inquiries if necessary and, I authorize to release my personal dala outside of lndonesia in the course of prGessing.

I consent to release my personal data to a third parties lor background chsk purpose. I also consent the recipients oF such enquiries to provide the data requested.

I understand that my oFFer is that I may withhold my permission and that in such a case, no investigation will be done and my application for employment will not be processed
further

SiBnature

Applb.bn Foh - ryRerutud-0416

B*llding a bett*r
v**rking r+,ortd
PennvarnAN KESEHATAN
Henttu Sareuerur

Nama Lengkap:
FullName

Jenis Kelamin: 7. PrialMale

Sex 2. Wanita/Female

Tanggal Lahir: ........ Umur/Age: ......... Tahun/Year

Date of Birth

Status: 1. Belum kawin/Sing/e

Marital Sfatus 2. Menikah/Married
3. CerailDivorced

Data kesehatan (Bila ya, mohon dijelaskan)

Medical data (lf yes, p/ease explain)

1. Tinggi badan: cm Berat badan; kg

Height Weight

2. Dalam dua bulan terakhir, apakah Anda pernah sakit atau kecelakaan?
/n the /ast two months, have you ever been sick or had an accident?

3. Apakah Anda dalam keadaan sehat, dan tidak dalam keadaan cacat atau sakit jiwa?
Are you in good health, and not having a physical disability or mental disorder?

4. Apakah Anda dan/atau anggota keluarga dekat* Anda sudah pernah atau pernah dirawat
disebabkan karena salah satu penyakit atau masalah kesehatan yang tercantum di bawah
ini?
Have you and/or immediate members of your f amily* ever had or ever been treated f or any of
the following diseases or health problems?

a. Kelainan pada sistem peredaran darah (tekanan darah tinggi, serangan jantung, dll.)?
Circulatory Sysfem Disorder (hypertension, heart attack, etc.)?

b. Kelainan pada sistem pernafasan (TBC, asma, pneumonia, dll.)?

Respiratory System Disorder (TBC, asthma, pneumonia, etc.)?

c. Kelainan pada sistem saluran kencing? (batu ginjal, penyakit kelamin, dll.)?
Urinary System Disorder (kidney stone, venereal disease, etc.)?

d. Kelainan pada sistem pencernaan (hati, kandung kemih, usus halus, dll.)?
Diqestive Sysfem Disorder (liver, gallbladder, intestine, etc.)?

Health Statement - Recruitment 02118

 e. Kelainan pada sistem syaraf (epilepsi, kelainan mental/gangguan cemas, dll.)?
Neryous Sysfem Disorder (epilepsy, mental illness/nervous disorder, etc.)?

f Kencing manis, kanker, tumor, atau luka berat ?

Diabetes, cancer, tumoLtr, or seyere bodily injury?

S. Kelainan pada kulit, kurang gizi, infeksikronis, atau saran untuk menjalankan test HIV?
Skin disorder, undernutrition, chronic infection, or advised to undergo an HIV test?

h Penyakit-penyakit lain yang tidak disebutkan di atas?

Other diseases not mentioned above?

5. Apakah Anda pernah atau dianjurkan untuk menjalanioperasi, diperiksa oleh dokter, atau
sudah pernah menjalankan pemeriksaan kesehatan (tes darah, pemeriksaan sinar X,
elektrokardiogram, dll.) selama dua tahun terakhir ini?
Have you had or been advised to have an operation, been treated by a doctor, or had a
medical check up (blood test, X'ray, ECG, etc.) ln fhe /asf two years?

6. Khusus untuk wanita:

Apakah Anda sedang hamilsekarang? Bila ya, dalam keadaan hamil ..... bulan
For female:
Are you currently pregnant? /f so, stage of pregnancy is ..... monfhs

PrRNverneu onN PrN4seRrnu Kunsn:

Srur tu mr nN o A uru on z ar nN :

Dengan ini saya menyatakan bahwa pernyataan saya ini semua benar, dan saya mengerti dan setuju bahwa apabila
pernyataan saya ini tldak benar, maka Perusahaan berwenang untuk menindaklanjutinya ke pihak yang berwenang
termasuk namun tidak terbatas untuk melakukan proses pemutusan hubungan kerja sesuai ketentuan dan peraturan
perundang-undangan yang berlaku Dengan Pernyataan ini, saya memberi kuasa kepada semua dokter di rumah
sakit, klinik, perusahaan asuransi, atau perusahaan/lembaga, atau yayasan, atau perorangan, untuk membuat dan
mengirim laporan/ pernyataan ke Perusahaan mengenai kesehatan saya Fotocopy dari pemberian kuasa atas
pernyataan ini akan dianggap sah berdasarkan hukum sebagaimana dokumen aslinya
I hereby declare all statements made herein to be true, and understand that if any statement herein is found to be
f alse that the Firm is entitled fo process such f alse information to the relevant authorities including but not timited to
process termination of employment agreement in accordance with prevailing laws and regulations. With this
statement I also authorize any doctor in any hospital, clinic, lnsurance Company, or company/institution, or
foundation, or any other person, to prepare and submit a report/statement to the Firm concerning my state of heatth
Any copy of this statement of authorization is to be considered as legally binding as the original document

Date/Year

(Nama, Tandatangan)
Name, Signature

*) Yanq dimaksud dengan anggota keluarga dekat adalah ordng tua, kakak/adik, pasangdn, dan anak (lmmediate members ot
the family mean your parents, brothers/sisters, spouse and children)

Health Statement - Recruitment 02l'18