Employment Application Form Mayapada Healthcare Group 1 [PDF]

Citation preview

EMPLOYMENT APPLICATION FORM POSITION APPLICATION 1. POSITION APPLIED :



perawat anestesi



DATE OF INTERVIEW



11-Dec-20



2. HOW DID YOU FIND THIS VACANCY ? LinkedIn



Recruitment Agency/Headhunter



Direct Application



Facebook



Jobstreet



Staff Referral



Others, please mention ____________



PERSONAL DATA 1. FULL NAME



Ficky Muhammad haryudi



2. SEX



laki laki



3. PLACE DATE OF BIRTH



Pandeglang



4. DATE OF BIRTH



12/1/1991



5. MARITAL STATUS



menikah



6. RELIGION



Islam



7. NATIONALITY



Indonesia



8. ID CARD/PASSPORT NUMBER



3602150112910000



9. NPWP NUMBER



808334536419000



10. SOCIAL SECURITY NUMBER (BPJS KETENAGAKERJAAN) 11. CURRENT ADDRESS



jl.salemba bluntas gang H.murtado 8 no.A696



12. PERMANENT ADDRESS (AS PER ID CARD)



Kp.pasir degung, kec.warunggunung, kab.lebak, prov.banten



13. CONTACT NUMBER



MOBILE 1 082298714364 MOBILE 2 RESIDENCE



14. EMAIL



[email protected]



15. SOCIAL MEDIA



LINKEDIN FACEBOOK Ficky Haryudi INSTAGRAM



ficky_haryudi



TWITTER



FAMILY INFORMATION (for married individual, please fill in spouse & children data) No



Name 1



intan lauwanda



Sex perempuan



Relationship



Education/ Occupation/ Company



istri



S2/Guru/ SMPN 6 depok



PARENTS AND RELATIVES DATA (for single individual, please fill in family members information) No



Name of Parents and Relatives



1



duddi saprudi



2



rosikah



3



ficky muhamad haryudi



4 5



fifi fatmawati rahayu arya cembawan wijaksana



Sex



Relationship



Date of Birth



City



Education/ Occupation



laki laki



ayah kandung



6/7/1960



pandeglang



SMA/Wiraswasta



perempuan



ibu kandung



10/9/1965



pandeglang



S1/guru



laki laki



anak pertama



1/12/1991



pandeglang



S1/perawat



perempuan laki laki



anak kedua anak ketiga



9/1/1997 10/4/2003



pandeglang pandeglang



S1/perawat kuliah/pelajar



EMERGENCY CONTACT No



Name



Relationship



Address



Phone Number(s)



EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP



1



1



intan lauwanda



istri



8979996946



jl.program IVB pancoran mas depok



FORMAL EDUCATION No 1 2



School/ Institution



City



akademi keperawatan yatna yuana lebak banten universitas esa unggul jakarta barat



Year of Graduation 2013 2019



Major keperawatan kesehatan masyarakat



Qualification Obtained keperawatan K3



GPA 3.29 3.02



LANGUAGE No



Language



1



inggris



Spoken moderate



Written moderate



Reading moderate



(Low/ Moderate/ High) (Low/ Moderate/ High) (Low/ Moderate/ High)



PROFESSIONAL LICENSES OR CERTIFICATION No



Name of Certification



1



BTCLS/BCLS



2



Anastesi



Name of Institution pro emergency



Years Obtained 2017



RSUP.dr.Sardjito Yogjakarta 2017



WORK EXPERIENCE Current Company rumah sakit royal progress



Company Name Company Address Latest Position



Sunter Paradise 1, Jl. Danau Sunter Utara, RT.6/RW.12, Sunter Agung, Tj. Priok, Kota Jkt Utara, Daerah Khusus Ibukota Jakarta 14350



perawat anastesi



Date (DD/MM/YYYY)



Start Date



2020



Starting Salary Latest Salary



8000000



Reason for leaving



mencari pengalaman yg lebih baik



End Date



sekarang



End Date



01-Sep-18



8500000



021-6400261 May we contact this current/ previous employer directly? If yes, please provide name, contact number If not, please explain why Achievement(s)



Previous Company rumah sakit sint carolus jakarta pusat



Company Name Company Address Latest Position Date



jl.salemba raya no.41 jakarta pusat perawat anastesi (DD/MM/YYYY)



Start Date



2013



Starting Salary Latest Salary



4500000



Reason for leaving



menyelesaikan skripsi karena sedang kuliah



6000000



021-3904441 May we contact this current/ previous employer directly? If yes, please provide name, contact number If not, please explain why Achievement(s)



menjadi asisten dokter anastesi konsultan anastesi nyeri, dan regional.



EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP



2



Previous Company Company Name Company Address Latest Position Date



(DD/MM/YYYY)



Start Date



End Date



Starting Salary Latest Salary



Reason for leaving May we contact this current/ previous employer directly? If yes, please provide name, contact number If not, please explain why Achievement(s)



ORGANIZATION STRUCTURE (please draw organization structure showing your position in your current company) kepala anastesi



dokter anastesi



perawat anastesi



saya



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



Name : Company :



Contact No : Job Position : Years Known : Relationship :



Name : Company :



81299065328 perawat teman



Contact No : Job Position : Years Known : Relationship :



CURRENT DETAILS OF SALARY AND BENEFITS 1. Monthly basic salary gross



8000000



IDR



2. Eligible for over time ?



yes



( Yes / No )



If yes, monthly average ? 3. Allowances Meal



2000000



Transportation



800000



IDR



Phone/ Handphone



300000



IDR



Others



IDR



4. Loan facilities Type of Loan



Housing



Car



Outstanding Amount



Personal Max Limit



Interest per Year



% Outstanding Period Repayment Methods



5. Annual Leave



100000



(Days)



9000000



IDR



(months/ years) (months/ years)



6. Annual Bonus : THR (Festive Allowance) Performance Bonus



IDR



Others, please explain



IDR



EMPLOYMENT APPLICATION FORM MAYAPADA HEALTHCARE GROUP



3



7. Medical Benefits



Cashless



Reimburstment



Out Patients (Per Year)



IDR



In Patients (Room & Board)



IDR



8. Life Insurance 9. Other Benefits, Please Explain:



80000 IDR BPJS kesehatan dan kenagakerjaan



COMPENSATION BENEFIT EXPECTATION & COMMENCEMENT 1. Monthly salary (Gross)



9500000



IDR



2. Benefits / Others 1 januari 2021



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.



yes, yohana dan indah mayapada kuningan



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)



No



If yes, please state where, when and cause



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)



No



If yes, please provide details.



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)



No



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.



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?



No



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.



7. Do you have any other job or business activities outside the current employment?



No



If yes, please provide the detail including name of enterprise, type of business, position and starting year of the position.



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.



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



4