Private & Confidential

EMPLOYMENT APPLICATION FORM

Please attach
photo here
4cm x 6cm

To:

Human Resource Department

Position applied for:

How did you learn about this vacancy:

Section A : Personal Information

MIFTAHUL ULUM
Full Name (capital letter): __________________________________________________
Sex: Male/Female
Date of Birth:

Februari 19, 1976

Kendal
________________________
Place of Birth: _______________________________
Islam
______________________________________________________________________

Religion
Full Address:

Pondok Sirnabaya Indah Blok A no. 1 RT 008/005 Sirnabaya. Karawang

_____________________________________________________________________

Contact Number:

085288601979
________________________ Hand Phone: _______________________________

Email Address:

miftahul1977@gmail.com
_____________________________________________________________________

ID Card Number:

3215011902760004
17-12-2015
Issued by: _________________ on:_____________
f _______________________

Passport Number:

________________________ Issued by: _________________ on:_____________

Marital Status:

Married
3 person
________________________
No. of Children: _____________________________

Family (including mother, father, brother, sister, spouse & children if any)
Name

Kanin

Relationship

Date of Birth

Occupation

Father

Aisyah

Mother

Ahmad Zamroni

Brother

Nurwahidah

Sister

Company

businessman
-

List two persons as your emergency contact.

Name

Dessy Herliani

Relationship

wife

Telephone

Mobile

082114207823

Address

Karawang

Section B : Education**
List below your last attendance at University/College/School
Institution(s)

From Year to Year

Place

Qualification
Obtained

Graduated

Singaperbangsa University

1998 - 2004

Karawang

STM N Kendal

1993 - 1996

Kendal

Pass

SPM N 1 Kendal

1990 -1993

Kendal

Pass

SD N Bandengan 1

1983 - 1989

Kendal

Pass

*) pick one by crossing the unnecessary information / **) Please attach certified copies of your certificates

Section C : Employment History

Provide information for the last 10 years, starting with the most recent employment. If space
provided is insufficient, please attach separate sheet.
Company
1

PT. Onamba Indonesia

From
(MM / YR)

June 2014

To
(MM / YR)

Present

Position(s) Held

Personnel & GA Head

Last Salary

IDR 13.000.000

Reasons for Leaving:

Duties/Responsibilities:

Manage and control Personnel and General Affairs departement's activities

May we contact this current / previous employer?

If yes, please provide name and contact number.
If not, please explain why.
2

Oct 1996
PT. Asia Pacific Fibers, Tbk
Got better salary

YES / NO

Firman Hidayat 081316546191

June 2014

HRD Ass. Manager

Reasons for Leaving:

Duties/Responsibilities:

Manage personnal matters example :HRIS, training & development, Absenteeism,

Industrial Relation,Health Insurance etc
May we contact this current / previous employer?
If yes, please provide name and contact number.
If not, please explain why.

YES / NO

Ujang Sarpendi 083814368272

3
Reasons for Leaving:

Duties/Responsibilities :

May we contact this current / previous employer?

If yes, please provide name and contact number.
If not, please explain why.

YES / NO

IDR 7.500.000

4
Reasons for Leaving:

Duties/Responsibilities

May we contact this current / previous employer?

If yes, please provide name and contact number.
If not, please explain why.

YES / NO

Section D: Skills and Training

List other skills or training that support this application
Skill / Training Course

Institution

Certification /
Proficiency

Year

MSDM for beginners profesional

HRD Club

Certificate of attendance

2014

HR Brotherhood super camp

HRD Forum

Certificate of attendance

2014

OD Specialist program

Value Consult

Certificate of competence

2012

Supervisory Management

SIS Consulting

Certificate of attendance

2012

English Business Course

Global Education

Level 1

2012

Section E: Languages
Language

English

Spoken*

Written*

Poor / Fair / Good

Poor / Fair /Good

Poor / Fair / Good

Poor / Fair / Good

Poor / Fair / Good

Poor / Fair / Good

Section F: References
List two persons not related to you, who are familiar with your character, background or work
performance, which we may contact at any time.
Name:
Address:

Name:
Address:

Firman Hidayat
_______________________________________

Contact No.:

081316546196
___________________________________

_______________________________________
PT. Onamba Indonesia

Occupation:

___________________________________
Production Manager

_______________________________________

Years Known:

2 years
___________________________________

Ujang Sarpendi
_______________________________________

Contact No.:

083814368272
___________________________________

PT. Asia Pacific Fibers

_______________________________________
_______________________________________

Occupation:
Years Known:

HRD
___________________________________

10 years
___________________________________

Section G : Other
Expected salary

Estimated date of join

IDR 16.000.000

one month after notice

Section H : Declarations and Authorizations

THIS APPLICATION IS NOT COMPLETED UNTIL THE FOLLOWING STATEMENT HAS BEEN READ AND SIGNED.
Have you ever been convicted of a criminal offence anywhere in the world, excluding
convictions that have been set aside or quashed? If yes, please provide details below.
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 or dismissal
from employment at DHL.
Details:

Yes

No

Yes

No

Yes

No

Have you ever been dismissed or suspended from any position, or subject to internal disciplinary
action by any of your previous employers? If yes, please state where, when, and cause.
Details:

Do you have any immediate family members working in this company? If yes, please state the
name of the employee, designation, and relation.
Details:

I certify that all the information provided in this application is true, complete and correct to the best of my knowledge. I
understand that any false information or omission may lead to dismissal or disciplinary action.

I authorize DHL (and its parent, subsidiaries, affiliates or agents) 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.

To the extent permissible under the law, I release DHL and all other persons, companies or organizations, from any and
all liability to me arising from providing or receiving such information relating to me. DHL will only use information
collected in connection with your employment with DHL.

MIFTAHUL ULUM

Karawang, March 15, 2016

Signature

Date

Thank you for completing our DHL Application Form

DHL- Supply Chain Indonesia
Graha Intirub Bussines Park Build, 1st floor
Jl.Cililitan Besar No. 454 East Jakarta 13650 INDONESIA
Tel +62 (0) 21 29379030 Fax +62 (0) 21 29379050
www.dhl.com