410008224.

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APPLICANT PERSONAL INFORMATION

Job applied :
Medical Doctor
Full name/ nickname : Gerry Juliansyah

Address within town (complete) : Jl. Kikim 1 Blok V No. 2 Rt. 25 Rw. 7 Palembang

Email address Gerry.j_fk@yahoo.co.id Phone no : (+62)85286864941

Address (outside town) :

Phone :
M
Male Height Weight Religion Nationality
Female 170Cm 62Kg Islam Indonesia
Birth Marital Status
Place of birth: Date : Month : Year : Unmarried Widow/Widowe
Palembang 18 7 1989 •
Married Divorce

House / Residence V
Privately Rent Type/ Brand/
Boarding House
Owned Year
Family
Others : Family Owned Ownership
Owned

Family tree (including yourself)

Family Education Job
Name M/F Age
Relationship Position
Father Soeherman M 58th S1 Staff
Mother Nurdiyanti F 53th S1 Staff
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Sibling 5
Sibling 6
Sibling 7

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Sibling 8
Sibling 9
Sibling 10

Spouse Kiki Kurnia Dewi F 29th DIII

First Child Assyifa Salsabila Balqis F 5th
Second Child Khanza Zahira Zarqa F 3th
Third Child Sultan Muhammad Alfatih M 1th
Fourth Child
Fifth Child
Sixth Child

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TION
Please fill this form with complete and clear
information .

Photo 4 X 6
Please attach

Email address
ID Card No:

Driving License A :
No:
C:
Vehicle

Self-owned Parents

Company Others

Job
Description
Company
PNS
PNS

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Education History (Formal/Informal)

Year
Level Name City/Palce Major Pass/ Not
From To
Secondaru School SD Kartika II-3 Palembang 1994 2000 Pass
Junior High School SMP N 1 Palembang 2000 2003 Pass

Senior High School SMA N 2 Palembang 2003 2006 Pass

Diploma
University SMA N 1 Palembang 2006 2013 Pass

Course/ Training
Type Enforcement City/ Place Duration Year Financed by

Hiperkes Mei Palembang 3 Days 2013 Kemenakertrans

ACLS Mei Palembang 6 Days 2017 PERKI

Language Ability : (Please fill : Excellent , Good , Moderate, Poor )

Language Listening Reading Speaking Writing

English Moderate Good Good Moderate

Social activities :
Organization Types of activities Position Year

Hobbies and activities during spare time :

Sport

You read :
a lot Topics that you read :

average ……………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………
less
……………………………………………………………………………………………………………………………

What types of magazine/ newspaper do you usually read ?

Newspaper : ………………………………………………………………………………………………………………………………………………………..
Magazine : ………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………..

2
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Employment History : Starting from your present job

A Month Year Name/Address/Company Phone No
From: 2014 Talisman
To : 2015
Type of Business : Oil No of employees :
Name of direct superior : Director Name :
Reason of resignation :

B Month Year Name/Address/Company Phone No

From:
To :
Type of Business :
Name of direct superior :
Reason of resignation :
2015
2016
Laboratorium Clinic No of employees :
Director Name :

C Month Year Name/Address/Company Phone No

From: 2017
To : 2018
Type of Business : Hospital No of employees :
Name of direct superior : Director Name :
Reason of resignation :

D Month Year Name/Address/Company Phone No

From:
To :
Type of Business : No of employees :
Name of direct superior : Director Name :
Reason of resignation :

E Month Year Name/Address/Company Phone No

From:
To :
Type of Business : No of employees :
Name of direct superior : Director Name :
Reason of resignation :

Reference ( People to inquire regarding your personal informatio

Name Address / Telephone

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People to contact during emergency

Name Address / Telephone

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ur present job
Phone No Position
Beginning : Medical Doctor
End :

Salary:

Phone No Position
Beginning : Physical Doctor
End :

Salary:

Phone No Position
Beginning : Doctor Verificator
End :

Salary:

Phone No Position
Beginning :
End :

Salary:

Phone No Position
Beginning :
End :

Salary:

rsonal information )
Job Relationship

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ncy

Job Relationship

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PLEASE DEFINE YOUR RESPONSIBILITIES FROM YOUR PREVIOUS J

Sebagai dokter verifikator BPJS yang bertanggung jawab untuk claim BPJS di Rumah Sakit.

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PLEASE DRAW THE ORGANIZATIONAL STURCTURE DEFINING YOUR PO

IN YOUR PREVIOUS WORKPLACE

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ANSWER
QUESTION
Yes No Descript
Have you ever applied at this company group before?
If yes please specify the time and the position. No
Aside from this company, where else are you applying at?
And for what posItion? No
Are you still under contract with the company
you are working at? No
Do you have side job or part time job? Praktek Dokte
If yes please specify the place and time period Yes
Do you mind if we ask reference from the company Amelia, as a P
you have worked before? Yes
Do you have relative or friend working in this company
or group companies? Please specify No
Have you suffered from chronic or terminal illness
or experienced severe accident and surgery?
If yes please specify the type of illness and the time No
Have you ever had pshycology examination Pada tes CPN

or psychotest? If yes please mention when and for what

reason Yes
Have you ever dealt with the police
got involved in crime? No
If you got accepted, would you be willing to serve Yes Sesuai dengan penempat
out of town?
Please mention the name of the city and area
Which types of job or position are suitable
with your dream? Sesuai dengan keterampilan dan kompetensi yang sa
What types of job do you dislike? pekerjaan diluar kompetensi
What is your salary and the facilities that you enjoy
from your present job?
If you get accepted, what is the salary and
genai salary
theyang
facilities
pantas.
that
Disamping
you would
tentunya
like to juga
have?
saya yakin perusahaan telah mempunyai ketentuan yang dapat diberika

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If you get accepted, when will you able to start working? Kapan saja perusahaan membu

I hereby declare that the information I gave is all true.

When it turns out that there is unreal, I will take full responsibility for the consequences.

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ANSWER
Description

Praktek Dokter Umum

Amelia, as a PIC BPJS

Pada tes CPNS Polri

esuai dengan penempatan yang dibutuhkan

dan kompetensi yang saya punya yaitu dokter umum.

rjaan diluar kompetensi saya

tuan yang dapat diberikan kepada saya mengingat pengalaman serta posisi pekerjaan di perusahaan ini. Untuk memulai pe

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saja perusahaan membutuhkan

nces.

Palembang, 5 April 2018

Dr. Gerry Juliansyah

Applicant

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