Form data pribadi karyawan-

`PT. SOLOBHAKTI TRADING & CONTRACTOR
JL. WELIRANG NO 26 SURABAYA
RAHASIA
CONFIDENTIAL


DATA PRIBADI KARYAWAN


PERSONAL RECORD

" "

1. Nama
Name ______________________________________




2. KTP No . -------------------------------------
----------------------

3. Jenis Kelamin
Sex ______________________________________

4. Alamat Rumah
Home Address ______________________________________


______________________________________

______________________________________
5. Telepon
Telephone ______________________________________

6. Tempat & Tanggal lahir
Place&Date of Birth ______________________________________

7. Agama
Religion ______________________________________

8. Kewarganegaraan
Nationality ______________________________________

9. Suku Bangsa
Race ______________________________________





10. Status Perkawinan

Marital Status


" " Belum Kawin "

" " Belum Kawin " Tahun : "
" " "_______________ "


Single
Since

" " Menikah " Tahun : "
" " "_______________ "


Married Since

" " Bercerai " Tahun : "
" " "_______________ "


Divorce
Since

" " Janda/ Duda " Tahun : "
" " "_______________ "


Widow /Widower Since
11. Tinggi dan Berat Badan

Height & Weight
: _______________


II . Keadaan Keluarga


Family

1. Susunan Keluarga Sekandung ( Termasuk diri sendiri )
Family (Including The Candidate)


" "Nama "L/P " Usia "Pendidika"Pekerjaan "
" "Name " "Age "n "Accupation"
" " " " "Education" "
"Ayah " " " " " "
"Father " " " " " "
"Ibu " " " " " "
"Mofher " " " " " "
"Saudara " " " " " "
"1 " " " " " "
"1st Chid" " " " " "
"Suadara " " " " " "
"2 " " " " " "
"2nd " " " " " "
"Child " " " " " "
"Saudara " " " " " "
"3 " " " " " "
"3rd " " " " " "
"Child " " " " " "
"Saudara " " " " " "
"4 " " " " " "
"4th " " " " " "
"Chid " " " " " "
"Saudara " " " " " "
"5 " " " " " "
"5th " " " " " "
"Chid " " " " " "
"Saudara " " " " " "
"6 " " " " " "
"6th " " " " " "
"Child " " " " " "
"Saudara " " " " " "
"7 " " " " " "
"7th " " " " " "
"Child " " " " " "
"Saudara " " " " " "
"8 " " " " " "
"8th " " " " " "
"Child " " " " " "


( Bila sudah meninggal dunia berilah tanda (* ) , lalu sebutkan pendidikan
dan pekerjaan terakhirnya )
please mark ( * ) to the person already passed away and mention his/her
last educational occupation
2. Bila sudah menikah lengkapilah data berikut ini :
If you are married, please fill in this table :


" "Nama "L/P " Usia "Pendidika"Pekerjaan "
" "Name " "Age "n "Occupation"
" " " " "Education" "
"Istri " " " " " "
"/Suami " " " " " "
"Wife " " " " " "
"/Husband " " " " " "
"Anak 1 " " " " " "
"1st Child " " " " " "
"Anak 2 " " " " " "
"2nd Chid " " " " " "
"Anak 3 " " " " " "
"3rd Child" " " " " "
"Anak 4 " " " " " "
"4th Child" " " " " "
"Anak 5 " " " " " "
"5th Chid " " " " " "


( Bila sudah meninggal dunia berilah tanda ( * ), lalu sebutkan
pendidikan dan pekerjaan terakhirnya )
Please mark (*) the person already passed away and mention his /her
last education occupation.


III PENDIDIKAN DAN KETERAMPILAN :
Educational And Skill

1. Formal


"Tingkatan "Nama "TEMPAT SEKOLAH "MASUK "KELUAR "
"Level "Name "Place "Entry "Graduate"
"1.. SD " " " " "
"Elementary " " " " "
"2. SMP " " " " "
"Jr.High School " " " " "
"3. SMA " " " " "
"High School " " " " "
"4. " " " " "
"Akademi/Diploma " " " " "
"Academy " " " " "
"5. Strata 1 " " " " "
"Under Graduate " " " " "
" " " " " "
"6 Pasca Sardajana" " " " "
" " " " " "
"Post Graduate " " " " "












2. Non Formal

"Kursus /Penataran"Tahun "Lama Kursus "Dibiaya oleh "
"Course/Traning "Year "Duration "Sponsored By "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "

3 Penguasaan Bahasa Daerah & Asing
Language Ability


"Bahasa "Kemampuan "Kurang "Cukup "Baik "
"Language "Ability "Poor "Fair "Fluent "
" "Menulis / Writing " " " "
" "Membaca /Reading " " " "
" "Berbicara/Speaking " " " "
" "Mendengar/Listening" " " "
" "Menulis / Writing " " " "
" "Membaca /Reading " " " "
" "Berbicara/Speaking " " " "
" "Mendengar/Listening" " " "
" "Menulis / Writing " " " "
" "Membaca /Reading " " " "
" "Berbicara/Speaking " " " "
" "Mendengar/Listening" " " "
" "Menulis / Writing " " " "
" "Membaca /Reading " " " "
" "Berbicara/Speaking " " " "
" "Mendengar/Listening" " " "

*) Berilah tanda ( X) pada tempat yang sesuai
Please mark ( X ) in the appropriate place







IV PEKERJAAN
Occupation

1. Riwayat Pekerjaan dimulai dari Pekerjaan yang terakhir

Work Experience, starting from the current job



"Tahun / "Nama & "Bidang "Jabatan "Gaji "Alasan "
"Periode "Alamat "Usaha "Terakhir "Terakhir "Berhenti "
" "Perusahaan " " " " "
"Year/Peri"Company Name "Lines "Last " "Reason of "
"od "& Address "of "Position "Last Salary "Leaving "
" " "Busines" " " "
" " "s " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "


2. Prestasi atau penghargaan yang pernah diperoleh selama bekerja

Outstanding achievement and accomplishment in work








3. Jabatan yang dilamar :
Position applied

4. Jumlah gaji yang dharapkan :
Expected salary

5. Tunjangan yang diharapkan :
Expected benefit





6. Alasan untuk melamar pada jabatan tersebut

Reason (s) for applying the position

















V KEGIATAN LAINNYA

Other activities


1. Hobi/ kegemaran :

Hobby /interest







2. Organisasi yang masih atau pernah diikuti
Participation in organization ( s) :


"Nama "Jenis Organisasi"Tahun/Periode "Jabatan "
"Name "Type "Year/Period "Position "
" "Organization " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "

3. Pengalaman memimpin ( didalam maupun diluar pekerjaan )
Leadership experience ( in the job and in social activities )












VI DATA KESEHATAN

Others
1. Apakah anda pernah menderita Sakit berat sampai pernah dirawat dirumah
sakit atau
menderita penyakit yang lama sembuhnya ?
Have you over been hospitalized and /or seriously ill for a long time ?



" "Tidak "
" "pernah "
" "Never "




" "Pernah "
" "Yes "


Tahun :
When
Lama sakit :
How Long
Penyakit :
Name of illness
Dirawat di :
Name of Hospital

2. Pernakah saudara mengalami kecelakaan ? Bila ya , sebutkan dan jelaskan
akibat dari
kecelakaan tersebut !


3. Golongan darah

4. Apakah saudara mempunyai kebiasaaan meminum minuman berakohol ?

5. Apakah saudara merokok ? Berapa bungkus /hari ?
________________________

6. Apakah didalam keluarga . anda ( orang tua /saudara kandung ) ada yang
mengindap
penyakit kronis ( jantung/ diabetes / darah tinggi/ asam dll ) ?
Siapa ? ___________

7 . Apakah dalam 12 ( dua belas ) bulan mendatang ada rencana untuk
dirawat dirumah
sakit / melakukan pengecekan kesehatan ?
_________________________________

8. Apakah saudara pernah / sedang menderita penyakit atau gejala penyakit
dibawah ini :

a. Sering demam dalam waktu lama ( ) Ya ( )
Tidak
b. Sering diare ( ) Ya ( ) Tidak
c. Sesak nafas/asma
( ) Ya ( ) Tidak
d. TBC / batuk yang lama
( ) Ya ( ) Tidak
e. Ganguguan pencernaan , tukak lambung (
) Ya ( ) Tidak
f. Lever/hati
( ) Ya ( ) Tidak
g. Pusing,nyeri dada
( ) Ya ( ) Tidak
h. Jantung
( ) Ya ( ) Tidak
i. Darah tinggi/darah rendah (
) Ya ( ) Tidak j. Ginjal /saluran kemih
( ) Ya ( ) Tidak
k. Ayan
( ) Ya ( ) Tidak
l Tumor/ kanker
( ) Ya ( ) Tidak
m. Gangguan cacat badan/fisik (
) Ya ( ) Tidak
n. Gangguan kesehatan jiwa (
) Ya ( ) Tidak
o. Penyakit Kelamin
( ) Ya ( ) Tidak
p. AIDS /HIV
( ) Ya ( ) Tidak
q. Lain-lain yang belum disebutkan disini
___________________________________

( HARAP DIISI DENGAN SEBENARNYA DAN AKAN DIEVALUASI KEBENARANNYA PADA SAAT
BEKERJA / MENGAJUKAN IJIN SAKIT )

9. Nama dokter / rumah sakit yang anda kunjungi ( langganan) bila saudara
sakit ____________

_____________________________________________________________________

VII. KETERANGAN LAINNYA :
Others

1. Apakah anda pernah mengikuti enaluasi psikologi ?
Have you ever taken phisycologi test ?


" "Tidak "
" "pernah "
" "Never "




" "Pernah "
" "Yes "


Tahun :
When
Tempat :
Where
Tujuan :
Reason

2. Reverensi dan rekomendasi dari anda dapat diperoleh dari :
Further reference and recommendation about the candidates can obtained
from :

"No."Nama "Alamat & Telepon"Pekerjaan"Hubungan dengan anda "
"No."Name " "Occupatio"Relationship with "
" " "Address& "n "candidate "
" " "Telephone " " "
" " " " " "
" " " " " "
" " " " " "
" " " " " "


Dengan ini saya menyatakan bahwa semua informasi yang disebutkan diatas
benar-benar akurat , informasi dan keterangan yang tidak lengkap atau palsu
dapat dijadikan alasan untuk menolak lamaran saya atau saya dapat
diberhentikan dengan tidak hormat apabila saya sudah menjadi karyawan dan
termasuk unsur penipuan .

I hereby acknowledge that all information provided herein is to the best on
my knowledge and accurate. Any material misrepresentation or omission of
information may be grounds for my prospective employer's decision to reject
my application or to terminate in the even I am hired .

3. - Apabila saya diterima sebagai tenaga kerja Perusahaan
ini , saya bersedia
menyerahkan Ijasah Asli saya untuk disimpan dikantor selama masa
kerja .
- Apabila saya diterima sebagai tenaga kerja Perusahaan ini saya belum
mempunyai NPWP , maka saya bersedia mengurus NPWP selambat-lambatnya
dalam waktu 1 ( satu ) minggu sejak saya diterima .
- Apabila saya diterima sebagai tenaga kerja Perusahaan ini, saya
bersedia megadakan pengecekan fisik lengkap, kesegaran jasmani, dan
rontgent paru-paru kepada dokter yang ditunjuk oleh Perusahaan.
- Apabila saya diterima sebagai tenaga kerja Perusahaan ini saya bersedia
mengikuti seluruh aturan yang ditetapkan tanpa kecuali .



Jakarta , ………..,……..,………


Yang bertanda tangan ,





( ………………………..)


===============================================================

NB :
- Apabila pengisian form melalui email, tetap harus dibubuhkan tanda
tangan & nama
terang.
- Pada saat interview supaya dibawa :
- KTP asli & foto copy
- KSK foto copy
- Ijazah asli & foto copy
- Referensi kerja asli & foto copy.