PHOTO
APPLICATION FORM

Name : ANDRI NURYANTO SAKSANA

ID Card No : 3215290811930000

Current Home Address : DUSUN KARAJAN, RT/RW 01/01, DESA MEKARJAYA, KECAMATAN PURWASARI
KABUPATEN KARWANG, JAWABARAT 41373
Sex : o Female Male

Telp. Np. Office : HP : 0856 9283 4217

Residence : Rumah Email : andrinuryantosaksana69@gmail.com
Emergency Contact :

Date of Birth : 11/8/1993 Age : 24

Place of Birth : Bandung
Marital Status : Belum Menikah Nationality : Indonesia
Race : sunda Religion: Islam
Driving License : Sim C Do you own a car : o Yes No

EDUCATION & PROFESSIONAL QUALIFICATION

FROM - TO NAME OF SCHOOL, COLLEGE STATE LEVEL ATTAINED MAJOR COURSE OR SUBJECT
(STATE DATE)

SDN 1 PURWASARI 2000-2005

SMPN 4 KLARI 2005-2008
SMKN 1 CIKAMPEK 2008-2011
UNISIKA 2011-2017

CURRENT REMUNERATIONS (In Rupiah)

CURRENT EXPECTED

Basic :
Transport : Rp.4500
Meal : Rp.7500
Medical :
Incentive :
Bonus :
Pension Fund :
BPJS : Rp.200,050
Take Home Pay :
PREFERENCES
Notice of Interview : KAMIS days
Availability to join : month (s) notice

EMPLOYEMENT HISTORY (Commence with current or last employment)

Date of Employment : 19 DESEMBER 2013
Date Employment Ended :
Name of Employer : PT. MURIAGUNG KARYA BAJA
Address of Employer : DESA PURWASARI, KEC PURWASARI, KAB KARAWANG

State nature of employer's business : STEEL FABRICATION

Position Held : STAFF QC REPORT
Name & designation of Immediate Supervisor : PORMAN
Total number of employee in company : 200 KARYAWAN
Number of staff supervised by you :
Give details description of duties/responsibilities : Saya membuat laporan produksi untuk 3 bagian,Assembly,
welding dan finishing

How did you get employed in this company : cukup baik

(Through Advertisement, Recommendation, etc)
Reason for Leaving : Gaji tidak sesuai
Last Drawn Salary :

Date of Employment :
Date Employment Ended :
Name of Employer :
Address of Employer :

State nature of employer's business :

Position Held :
Name & designation of Immediate Supervisor :
Total number of employee in company :
Number of staff supervised by you :
Give details description of duties/responsibilities :
How did you get employed in this company :
(Through Advertisement, Recommendation, etc)

Reason for Leaving :

Last Drawn Salary :

Date of Employment :
Date Employment Ended :
Name of Employer :
Address of Employer :

State nature of employer's business :

Position Held :
Name & designation of Immediate Supervisor :
Total number of employee in company :
Number of staff supervised by you :
Give details description of duties/responsibilities :

How did you get employed in this company :

(Through Advertisement, Recommendation, etc)
Reason for Leaving :
Last Drawn Salary :

FAMILY DETAILS
OCCUPATI
ON NAME OF
RELATIONSHIP NAME ADDRESS AGE PRESENT / EMPLOYER
PAST

Father SRIYANTO KARAWANG 47

Mother CUCU KOMAL KARAWANG 45
Brother/sister SUCI MULIA WATI KARAWANG 20
BUNGA SRISUKMAWATI KARAWANG 14
ALFIAN FAJAR SRIWIJAYA KARAWANG 3

Spouse
Children
LANGUAGES
INDONESIA ENGLISH CHINESE (SPECIFY) JAPANESE ………………. ………………..
SPOKEN o o o o o o
WRITTEN o o o o o o

HOBBIES,GAME & OTHER INTERESTS

OLAHRAGA
MUSIK

ADDITIONAL INFORMATION - Give any additional information which you consider may be of interest to a prospective employer
, if possible state why you believe you are suitable for the position you are applying
Saya menguasai AUTO CAD dan MS Office

ORGANIZATION CHART OF COMPANY MOST RELEVANT TO POSITION APPLIED FOR.

(previous or current employer)
State name of company, indicate where you fit in within the organization.

EMPLOYEMENT REFERENCES (From past & present employment)

NAME :
POSITION :
COMPANY NAME :
COMPANY ADDRESS :

TELP (OFFICE)/HP :

NAME :
POSITION :
COMPANY NAME :
COMPANY ADDRESS :
TELP (OFFICE)/HP :

PERSONAL REFERENCES (Give names or person of responsibility who have known you for at least 3 years)
NAME :
POSITION :
COMPANY NAME :
COMPANY ADDRESS :

TELP (OFFICE) :
HANDPHONE :
YEARS OF ACQUAITANCE :

NAME :
POSITION :
COMPANY NAME : :
COMPANY ADDRESS : :

TELP (OFFICE) :
HANDPHONE :
YEARS OF ACQUAITANCE : :

NAME OF COMPANIES WITH WHICH YOU HAVE PENDING APPLICATION FOR EMPLOYMENT
(Give dates of application)
1.
2.
3.

HAVE YOU APPLIED WITH THIS OFFICE BEFORE? o YES o NO STATE DATE :

FOR CONSULTANT'S USE ONLY

Indicate your impressions gained from interviewing the applicant by making an (x) on the scale of each heading

1. Appearance
o Very Untidy o Somewhat careless o Satisfactory Personal o Neat and tidy better o Unsually well
about personal appearance than average groomed and very
appearance appearance neat
2. Friendliness
o Appears very distant o Approachable; fairy o Warm, friendly; o Very Sociable and o Extremely

and aloof friendly sociable outgoing friendly; very warm

and outgoing
3. Poise
o At ease; jumpy o Somewhat tense; o Reasonable o Sure of himself/ o Extremely well

and very nervous easily irritated at ease herself composed

4. Personality
o Unsatisfactory o Doubtful o Average and o Very good; above; o Outstanding

satisfactory average excellent all

around
5. Conversational Ability
o Talks very little; o Tries to express o Average fluency and o Talks well and does o Excellent expression
expresses himself/herself clearly expression not waste words extremely fluent;
poorly forceful
6.Alertness
o Very slow to grap o Rather slow requires oGrasp ideas with o Quick to understand o Exceptionally alert
ideas more than average average speed perceives well understands new

explanation ideas instantly

7.Knowledge
o Poor, no appropriate o Limited knowledge o Average knowledge o Well informed; o Excellent knowledge
knowledge at all covering some areas not covering all knowledge covers with faultless

areas fully most areas coverage

8.Qualifications
o Not relevant to job o Some relevant to o Satisfactory; as o Very suitable o Ideal for job;

job good as might be for job perfect match

expected
9. Skill
o None approriate o Some skill in job o Reasonable o Well skill in job o Excellent skill and
area amount; average area ideal for job

for job
10. Experience
o No relation between o Some experience o Average; o Very good and o Excellent and
background and job in relevant area background cover relevant experience ideal background

job area
11. Drive and Initiative
o Poorly defined goals; o Make little effort o Average effort; o High desire to o Sets high goals;
acts without purpose to achieve goals some initiative achieve; strives hard always takes initiative

CONSULTANT RECOMMENDATION
Dressing and Appearance :

Language Ability/Voice :

Other Information/Comments :
Day/date Consultant's Signature

I HEREBY CONFIRM ALL THE ABOVE DETAILS TO BE TRUE AND CORRECT. I AUTHORISE PT KELLY SERVICES INDONESIA AND PT INTELLIGENCE HRSOLUTIONS INDONESIA TO
CARRY OUT REFERENCE CHECKS WITH PAST EMPLOYERS AND REFEREES IN CONNECTION WITH THIS APPLICATION. I AGREED TO GIVE MY LATEST COPY OF SALARY SLIP FROM
MY CURRENT EMPLOYER FOR THIS APPLICATION WHEN REQUIRED.

I ALSO AGREED NOT TO SEEK OR ACCEPT EMPLOYMENT EITHER DIRECTLY OR INDIRECTLY FROM ANY CLIENT PT KELLY SERVICES INDONESIA AND PT INTELLIGENCE
HRSOLUTIONS INDONESIA TO WHOM I HAVE BEEN SENT FOR AN INTERVIEW, FOR AT LEAST THREE MONTHS AFTER DATE OF INTERVIEW.

I ALSO AGREED IF, SHOULD I ACCEPT EMPLOYMENT WITH ANY CLIENT OF PT KELLY SERVICES INDONESIA AND PT INTELLIGENCE HRSOLUTIONS INDONESIA, AND LEAVE
WITHIN THREE (3) MONTHS OF THE DATE OF SELECTION, I AGREE TO PAY PT KELLY SERVICES INDONESIA AND PT INTELLIGENCE HRSOLUTIONS INDONESIA 50% OF MY
CONFIRMED 1ST MONTH’S SALARY. I UNDERSTAND THAT ANY MISREPRESENTATION OR OMISSION OF INFORMATION WILL BE SUFFICIENT REASON FOR WITHDRAWAL OF AN
OFFER OR SUBSEQUENT DISMISSAL, IF EMPLOYED.

Saya menyatakan bahwa semua informasi yang saya berikan di sini adalah benar. Saya memberikan wewenang kepada PT KELLY SERVICES INDONESIA AND PT INTELLIGENCE
HRSOLUTIONS INDONESIA untuk melakukan cek referensi kepegawaian dari perusahaan tempat saya bekerja sebelumnya dan kepada pihak yang berhubungan dengan aplikasi
ini.
Saya menyetujui untuk memberikan salinan slip gaji terakhir dari perusahaan tempat saya bekerja untuk keperluan aplikasi ini apabila diperlukan.

Saya juga setuju untuk tidak melamar atau menerima tawaran kerja baik secara langsung ataupun tidak langsung dari klien PT KELLY SERVICES INDONESIA AND PT
INTELLIGENCE HRSOLUTIONS INDONESIA, kepada siapa saya telah diproses untuk interview, sedikitnya 3 (tiga) bulan setelah tanggal interview dengan pihak PT KELLY
SERVICES INDONESIA AND PT INTELLIGENCE HRSOLUTIONS INDONESIA.
Saya juga setuju apabila setelah saya menerima pekerjaan dari klien PT KELLY SERVICES INDONESIA AND PT INTELLIGENCE HRSOLUTIONS INDONESIA. dan apabila dalam
waktu 3 (tiga) bulan terhitung sejak saya menanda tangani perjanjian kerja dengan klien Kelly Intelligence Selection, saya memutuskan keluar dari perusahaan tersebut,
maka saya bersedia membayar PT KELLY SERVICES INDONESIA AND PT INTELLIGENCE HRSOLUTIONS INDONESIA sebesar 50% dari nilai gaji saya pada bulan pertama di
perusahaan tersebut.

Saya memahami bahwa apabila ditemukan ketidak benaran dalam informasi yang saya berikan, maka hal tersebut dapat menjadi alasan yang cukup untuk penarikan dari
proses rekrutment yang sedang berlangsung atau pembatalan bagi surat perjanjian kerja, bilamana sudah ditandatangani.

Day/date Signature