NCCTCI

Nursing Competency
Course Training
Certification Indonesian

ARYA INTERNATIONAL BUILDING

Jl. Tanah Abang I No. 12 JJ. Jakarta Pusat
Telp (+62-21) 290 22748-49, Fax (+62-21) 290 22747
Email : indorim@yahoo.com

SURAT LAMARAN KERJA / APPLICATION FORM

- Semua isian harap ditulis dengan huruf cetak

Please print or type
- Berikan tanda "X" pada tanda sesuai pilihan anda.
Mark with an "X" on sign according your own selection.
Jabatan yang dilamar : ________________________
Post applying
Mengajukan lamaran berdasarkan : ________________________
To applied on base of

Iklan Diberitahu kawan

Advertisement
Diminta oleh Perusahaan
Called by Company
Gaji yang dikehendaki
Salary Desired
Informed by Your Friend
Lain - lain
Others
: ___________________________________

Nama Pelamar : (tulis nama lengkap)

Applicant's Name : ________________________________________ (write down full name)
Alamat :
Address : __________________________ Telepon Rumah: Telepon Kantor:
__________________________ Home Phone : ___________________ Office Phone : _______________
__________________________
Status Tempat Tinggal :
Home Status :
Rumah Sendiri Sewa Kontrak
Own Home Rent Contract
Ikut Orang Tua / Saudara Lain - lain
Live with parent / Brother / Sister Other

Jenis Kelamin : Keturunan / Suku :

Sex
___________________________
Kebangsaan / Warganegara
Nationality / Citizenship
___________________________
Tempat Lahir
Place Of Birth
___________________________
No. Kartu Penduduk
Citizenship Certificate No
___________________________
No. Paspor
Passport Number
: __________________________ Race / Ethnic Group :
: Agama :
: __________________________ Religion :
: Tanggal Lahir :
: __________________________ Date Of Birth :
: Tempat & Tgl dikeluarkan :
: __________________________ Place & date of issue :
: Tempat & Tgl dikeluarkan :
: __________________________ Place & date of issue : __________________________

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 NCCTCI
Nursing Competency
Course Training
Certification Indonesian

Habis Masa Berlaku Tanggal :

Date Of Expiry : __________________________

Berat Badan : __________________________ Tinggi : __________________________

Weight : __________________________ Height : __________________________
Warna Rambut : Warna Kulit :
Hair Color : __________________________ Complexion : __________________________
Kawinl / Belum Kawin : Jumlah Anak :
Marital Status : __________________________ Number Of Children : __________________________
Ciri Ciri Khas Badan :
Distinguish Marks :
__________________________________________________________________________________________________________________
Penggunaan Kaca Mata :
Wear Spectacles : Ya Negatif
Yes Negative
Tidak Positif
No Positive

Nama Istri / Suami : Tempat & Tgl Lahir :

Name Of Wife / Husband : _____________________________________ Place & Date Of Birth : ___________________

Nama Anak :
Childrens Name
1. ________________________________ : Jenis Kelamin : _____________________ Umur : ___________________
Sex Age
2. ________________________________ : : _____________________ : ___________________
3. ________________________________ : : _____________________ : ___________________
4. ________________________________ : : _____________________ : ___________________
Jumlah Tanggungan Keluarga Lain : Hubungan Keluarga :
Number Of Depends : __________________________ Relation in Family : ___________________
Nama Ayah : Umur :
Fathers Name : __________________________ Age : ___________________
Nama Ibu : Umur :
Mothers Name : __________________________ Age : ___________________
Alamat Orang Tua :
Parents Address : __________________________

RIWAYAT PENDIDIKAN / EDUCATION:

Sekolah Dasar Lulus Tahun: Nama & Alamat Sekolah:
Elementary School _____________ Passed On _____________ Name & Address Of School __________________________
Sekolah Lanjutan Pertama Lulus Tahun: Nama & Alamat Sekolah:
Primary School _____________ Passed On _____________ Name & Address Of School __________________________
Sekolah Lanjutan Atas Lulus Tahun: Nama & Alamat Sekolah:
Secondary School _____________ Passed On _____________ Name & Address Of School __________________________
Universitas Lulus Tahun: Nama & Alamat Sekolah:
University _____________ Passed On _____________ Name & Address Of School __________________________
Akademi Perhotelan Lulus Tahun: Nama & Alamat Sekolah:
Hotel Academy _____________ Passed On _____________ Name & Address Of School __________________________
Akademi Lain Lulus Tahun: Nama & Alamat Sekolah:
Other Academic _____________ Passed On _____________ Name & Address Of School __________________________
Kursus Lain-Lain Lulus Tahun: Nama_& Alamat Sekolah:
Others Course _____________ Passed On_____________ Name & Address Of School _____________________________

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 NCCTCI
Nursing Competency
Course Training
Certification Indonesian

KETERAMPILAN KHUSUS / SKILL:

Magnetic Mesin Hitung Mesin Jahit
Type ______________ Calculator ____________________ Sewing Machine ______________________
Steno Front Office / Computer
Short Land _______________ Hotel System ____________________ Komputer __________________________
Lain Lain Internet
Others _______________

PENGUASAAN BAHASA / PROFICIENCY IN LANGUAGES

Indonesia Baik Sekali Baik Cukup
Excellent Well Fair
English Baik Sekali Baik Cukup
Excellent Well Fair
French Baik Sekali Baik Cukup
Excellent Well Fair
Baik Sekali Baik Cukup
Excellent Well Fair

MENULIS / WRITEN
Indonesia Baik Sekali Baik Cukup
Excellent Well Fair
English Baik Sekali Baik Cukup
Excellent Well Fair
French Baik Sekali Baik Cukup
Excellent Well Fair
- ___________ Baik Sekali Baik Cukup
Excellent Well Fair

PENGALAMAN KERJA / WORK EXPERIENCES

1. Nama Perusahaan : Jabatan :
Company : __________________________ Position : __________________________
Masa Kerja : Nama Atasan :
Working Period : __________________________ Name Of Superior : __________________________
Gaji Yang Diterima : Kawan Terdekat :
Monthly Salary: Rp. : __________________________ Immediate Supervisor : __________________________
Alasan Mengundurkan Dlri :
Reason for Leaving :
__________________________________________________________________________________________________________________

2. Nama Perusahaan : Jabatan :

Company : __________________________ Position : __________________________
Masa Kerja : Nama Atasan :
Working Period : __________________________ Name Of Superior : __________________________
Gaji Yang Diterima : awan Terdekat :
Monthly Salary Rp. __________________________ Immediate Supervisor : __________________________
Alasan Mengundurrkan Dlri :
Reason for Leaving :
3. Nama Perusahaan : Jabatan :
Company : __________________________ Position : __________________________
Masa Kerja : Nama Atasan :
Working Period : __________________________ Name Of Superior : __________________________

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 NCCTCI
Nursing Competency
Course Training
Certification Indonesian

Gaji Yang Diterima Kawan Terdekat

Monthly Salary : Rp. ______________________ Immediate Supervisor : __________________________
Alasan Mengundurrkan Dlri
Reason for Leaving : _________________________

Jika ada pengalaman lain, bisa ditulis di kertas tersendiri.

If any additional employment, please write down on separate form.

REFERENSI / REFERENCES
Sebutkan dua orang referensi, alamat dan teleponnya
Name, address and telephone number of 2 (two) references

NAMA ALAMAT TELEPON HUBUNGAN

NAME ADDRESS PHONE RELATION

Sebutkan nama, alamat dan telepon orang terdekat yang mudah dihubungi apabila anda mengalami sesuatu kecelakaan dan lain-lainnya.
Name, address and telephone number of person to notify in case in any emergency.

NAMA ALAMAT TELEPON HUBUNGAN

NAME ADDRESS PHONE RELATION

Pernahkah anda menjadl anggota Angkatan Bersenjata ?

Have you ever served in the military services?

NAMA KESATUAN MASA KERJA PANGKAT

NAME OF FORCES WORKING PERIOD RANK

Sanggupkah anda bekerja dengan shift sebagal berikut:

Are you willing to work with shift as below:

09.00 - 17.00 07.00 - 15.00 07.00 - 15.00

08.00 - 16.00 15.00 - 23.00 16.00 - 23.00
23.00 - 07.00
15.00 - 23.00 23.00 - 07.00 15.00 23.00
23.00 - 07.00

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 NCCTCI
Nursing Competency
Course Training
Certification Indonesian

Sebutkan dua orang kenalan anda yang bekerja di Perusahaan ini:

Relatives or friends if any, employed by The Company:
NAMA ALAMAT HUBUNGAN LAMA PERKENALAN
NAME ADDRESS RELATION LENGTH OF ACQUAINTANCE

Sebutkan hal hal lain yang telah anda capai dalam pekerjaan terdahulu:
Name of your accomplishment in the previous employment:

Dalam bidang apa anda merasa paling mampu untuk bisa berhasil?
Mentioned in what field do you think, to are capable to do your best to be succeeded?

Demikian pernyataan sava secara resmi seperti tersebut di atas vang sava isi sesuai dengan kenvataannva dan apablla ternyata di kemudian
hari terbuktl ada isian vang palsu. Maka kami sanggup dikeluarkan tidak dengan hormat.I hereby certify that the above information given by me
are true to the best of my knowledge and understand that any false information given above will be penalized with immediate dismissal if
accepted into the establishment.

Saya ketahui sepenuhnya bahwa sebagai syarat utama bekerja pada Perusahaan ini dengan tahap sebagai berikut:
I fully understood that employment with This Company will be through conditions shown below:

Latihan Kerja B. Percobaan C. Masa Kontrak Kerja D. Masa Perpanjangan Kontrak

Job Training Probation Period Contract Period Prolong Contract Period

.......................,.20...

Name :__________________________________

(Applicants signature )

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 NCCTCI
Nursing Competency
Course Training
Certification Indonesian

DOCUMENT CHECKED AND COMMENT BY INTERVIEWER

I. WILL BE DONE BY PERSONNEL DEPARTMENT ONLY

1. Information Test : ______________________________________

2. Trade Test : ______________________________________

II. INTERVIEWED BY
1. OUTSTANDING 3. GOOD
NUMBER CODE: 2. EXCELLENT 4. FAIR 5. POOR

COMMENT
1. Personal Appearance
2. English
3. Education
4. Experience
5. Temperament & Attitude
6. Relationship
7. Intelligence
8. Family Background
9. General Knowledge
10. Leadership

REMARKS:

Suitable
Accepted
Not Suitable

INTERVIEWER'S SIGNATURE

DAT E D

FOR PERSONNEL DEPARTMENT ONLY

THIS ITEMS WILL BE DISCUSSED: REMARKS:

Acceptable as :
Level :
- Salary :
- Meal Allowance :
- W.P.A. :

THIS APPLICANT AGREE TO BE ACCEPTED

Position: Start Working:

Salary after discussed :

PROBATION PERIOD: AFTER PROBATION PERIOD:

Level : Level :
- Salary : - Salary :
- Meal Allowance : - Meal Allowance :
- W.P.A. : - W.P.A :

......................................., .......................................................................

_______________________________ _________________________________
Human Resources Manager General Manager

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