EMPLOYMENT APPLICATION FORM

POSITION APPLICATION

1. POSITION APPLIED : Perawat DATE OF INTERVIEW 4 April 2020

2. HOW DID YOU FIND THIS VACANCY ?

LinkedIn Recruitment Agency/Headhunter Direct Application Others, please mention ____________

Facebook Jobstreet Staff Referral

PERSONAL DATA
1. FULL NAME Alvin Indrafitra
2. SEX Laki9
3. PLACE DATE OF BIRTH Madiun
4. DATE OF BIRTH 24 April
5. MARITAL STATUS Single
6. RELIGION Islam
7. NATIONALITY Indonesia
8. ID CARD/PASSPORT NUMBER 3671082404900003
9. NPWP NUMBER 93.162.682.4-621.000
10. SOCIAL SECURITY NUMBER (BPJS KETENAGAKERJAAN) 000-2319095919
11. CURRENT ADDRESS jl.tebet dalam timir no 17 rt 04 rw 008 kel.manggarai kec tebet
Jakarta selatan
12. PERMANENT ADDRESS (AS PER ID CARD) Jl Jonggrang No 14 rt 018 rw 003 kel patihan kec manguharjo madiun jawa Timur

13. CONTACT NUMBER MOBILE 1 08999813142

MOBILE 2
RESIDENCE
14. EMAIL alvinlohh@gmail.com
15. SOCIAL MEDIA LINKEDIN
FACEBOOK
INSTAGRAM @homemedicalparamedicservis
TWITTER

FAMILY INFORMATION (for married individual, please fill in spouse & children data)
No Name Sex Relationship Education/ Occupation/ Company
1
2
3

PARENTS AND RELATIVES DATA (for single individual, please fill in family members information)
No Name of Parents and Relatives Sex Relationship Date of Birth City Education/ Occupation
1 Suwondo Laki-laki Ayah 3 Juli 1965 Madiun SMK
2 Indrawati Perempuan Ibu 3 Sept 1965 Madiun SMA
3 Alvin Indrafitra Laki-laki Anak 24 April 1990 Madiun Diploma 3
4 Aldo indrafico Laki-laki Anak 1 Mei 1991 Madiun STM

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 1

 EMERGENCY CONTACT
No Name Relationship Address Phone Number(s)
1 Aldo indrafico Adik Jl. Gubeng Raya surabaya 81382382995

FORMAL EDUCATION
Qualification
No School/ Institution City Year of Graduation Major Obtained GPA
1 SDN PASAR BARU 5 TANGERANG Tangerang 2002
2 SLTPN 12 TANGERANG Tangerang 2005
3 SMK 1 Industri MADIUN Madiun 2009 Teknik Instalasi
4 AKPER dr. SOEDONO MADIUN 2011 Keperawatan Diploma 3 2.99

LANGUAGE
No Language Spoken Written Reading
1 English Medium Medium Medium (Low/ Moderate/ High)
2 indonesia High High High (Low/ Moderate/ High)
3 Jepang Low Medium Medium (Low/ Moderate/ High)

PROFESSIONAL LICENSES OR CERTIFICATION

No Name of Certification Name of Institution Years Obtained
1 PPGD RSUD dr. MOEWARDI SOLO 2014
2 BTCLS PPNI 2017
3 HIPERKES PT. BIAK VEENER JAYA 2017

WORK EXPERIENCE
Current Company
Mojosemi Park And Forrest
Company Name
Company Address Magetan - Jawa Timur
Latest Position
Staff Medical klinik

Date (DD/MM/YYYY) Start Date 2014 End Date 2015

Starting Salary 1.500.000

Latest Salary 1.500.000

Reason for leaving Habis Kontrak

Yes
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why Bapak Dery : 081234579087

Achievement(s)

kan medis yang memerlukan tindakan dari petugas medis, seperti pemberian pertolongan BHD, ataupun rawat inap sesuai ASKEP disaat pemberian terapi medis

Previous Company
Laboratorium Klinik Waloja Medika
Company Name
Company Address Madiun - Jawa Timur
Latest Position
Perawat plebotomy

Date (DD/MM/YYYY) Start Date 2015 End Date 2016

Starting Salary 1.750.000

Latest Salary 1.750.000

Reason for leaving Habis kontrak

Yes
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why Dr. Rochmad Santoso : +6282228830423

Achievement(s)

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 2

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Company Name
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Company Address Tangerang - Banten
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Latest Position
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Date (DD/MM/YYYY) Start Date 2017 End Date 2018
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Starting
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Reason for leaving Merawat Orang Tua yang sedang sakit
Yes
May we contact this current/ previous employer directly?
If yes, please provide name, contact number If not, please explain why Bapak Ilman UGD : 082120175294

Achievement(s)

ih sebagai perawat UGD di RSIA SEPATAN MULIA

Melaksanakan prosedur sesuai askep dan SOP yang telah ditentukan, dan tanggap cepat disaat terdapat situasi emergency mengenai pasien
ORGANIZATION STRUCTURE
(please draw organization structure showing your position in your current company). Untuk tahun pengalama kerja berikutnya dikarenakan form nya kurang, di tahun
2019 saya bekerja di PT. BIAK VEENER JAYA PAPUA BARAT sebagai PARAMESIC EMERGENCY SITE minning and gas, alasan saya keluar karena adanya kerusuhan dan
kurangnya komunikasi (sinyal tidak ada) berikuy nomer Atasan saya ketika di PT BIAK VEENER JAYA ( Bu. DYAH, BAG KEUANGAN DAN SDM KARYAWAN :
082230383297

REFERENCES
List two person NOT related to you, who are familiar with your character, background or work performance (preferably your direct supervisor)

Name : Bpk. Ilman Contact No : Bpk. ILMAN UGD

Company : RSIA SEPATAN MULYA Job Position : 82120175294

Years Known :
Relationship : 1 TAHUN

Name : Bu. Dyah Contact No : Bu. DYAH SDM & KEUANGAN

Company : PT. BIAK VEENER JAYA Job Position : 82230383297

Years Known :
Relationship : 1 TAHUN

CURRENT DETAILS OF SALARY AND BENEFITS

1. Monthly basic salary gross 4.500.000 IDR
2. Eligible for over time ? ( Yes / No )
If yes, monthly average ?
3. Allowances
Meal
Transportation IDR
Phone/ Handphone IDR
Others IDR
4. Loan facilities Type of Loan Housing Car Personal
Outstanding Amount 950.000/month Max Limit
Interest per Year % Outstanding Period (months/ years)

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 3

 Repayment Methods (months/ years)
5. Annual Leave (Days)
6. Annual Bonus :
THR (Festive Allowance) IDR
Performance Bonus IDR
Others, please explain IDR

7. Medical Benefits Cashless Reimburstment

Out Patients (Per Year) IDR
In Patients (Room & Board) IDR
8. Life Insurance IDR
9. Other Benefits, Please Explain:

COMPENSATION BENEFIT EXPECTATION & COMMENCEMENT

1. Monthly salary (Gross) 4.500.000 IDR
2. Benefits / Others
3. If you are offered employment with us
when can you start work (or notice period) ?

DECLARATIONS AND AUTHORIZATIONS

1. Do you have any family members; as an employee, who working in this company? (Yes/ No)
If yes, please state the name of the employee, designation and relation.
No
2. Have you ever been dismissed or suspended from any position, or subject to internal disciplinary action by any of your
previous employers? (Yes/ No)
If yes, please state where, when and cause
No
3. Have you ever been convicted of a criminal offence anywhere in the world, excluding convictions that have been set aside
or quashed? (Yes /No)
If yes, please provide details.
No im clean
Disclosure of a criminal record will not necessarily disqualify you for employment. However failure to disclose such information may result in disqualification of your
application of dismissal from employment at MAYAPADAHEALTHCARE GROUP
4. Have you ever apply/ work in MAYAPADA HEALTHCARE GROUP? (choose one) (Yes/ No)
If yes, When ? For position ?
Where Last selection stage (for apply)

5. Are you currently holding any position in any political party or a candidate for any political office?
If yes, please provide the detail of position and political party and your joining date to that political party and the position that you are running for as candidate.
No
6. Is there any member of your immediate family an official or any government agency, an employee of any government agency,
an official of political party, or a candidate for political office?
If yes, please states the detail of the name, position/office held and the family relationship. Immediate family means husband, wife, children, mother, father, siblings.
No
7. Do you have any other job or business activities outside the current employment?
If yes, please provide the detail including name of enterprise, type of business, position and starting year of the position.
No

I certify that all the information provided on this application is true and complete to the best of my knowledge.
I understand that any false information or omission may lead to disciplinary action or summary dismissal without any compensation.
I authorize MAYAPADA HEALTHCARE GROUP to verify all information provided in this application, including employment history, educational background and references.
I authorize my previous employers and references indicated above to release any information they may have about me.
MAYAPADA HEALTHCARE GROUP will only use information collected in connection with my employment with MAYAPADA HEALTHCARE GROUP.

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 4

 Alvin Indrafitra

Signature & Name

To the extent required by law, you may request to review and correct personal data through the HR Department.

EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP 5