Jl. Brigjend Katamso, KM.18, Kel. Tj. Uncang, Kec.

Batuaji, Kota Batam,

CONFIDENTIAL
Rahasia Recent
Photograph of
APPLICATION FORM Applicant

1. Position Applied : Senior Shipping Officer

Posisi yang dilamar

2. Full Name (including aliases) (as in Passport : Ms. Heppi Elpa Zamli
Nama Lengkap (termasuk alias) (sesuai dengan Passport)
*(Mr/Madam/Miss)

Address (if non-citizen, give foreign address as well) HP / Tel. Office :

Alamat (jika tidak sesusi dengan KTP, beri alamat sebenarnya) 08117705577
Kavling Sagulung Baru Blok K-45, Sungai Binti, Sagulung Tel. (Res) / Rumah
-
E-mail address PASSPORT
Alamat e-mail [email protected] No : B2829875 Type :
IC No. Date of Birth Marital Status No Tipe

No. KTP Tanggal Lahir Status Perkawinan Issue Date : Jan, 11th 2016
21711145057700001 May, 05th 1977 Single Tgl Dikeluarkan
Citizenship Place of Birth Sex Expiry Date : Jan,11th 2021
Kewarganegaraan Tempat Lahir Jenis Kelamin Tgl Habis Berlaku
Indonesia Sukarami (Solok) Female Height (Tinggi) Weight (Berat)
Race Religion Shoe and Uniform Size 1,55Mtr 62 Kgs
Suku Agama Ukuran sepatu dan seragam Eye-sight (Penglihatan)
Minang Islam 39/L Kacamata / Normal : Kacamata (-4)

Father's Name : Abdul Rauf Occupation (Pekerjaan) : Retired Police officer

Nama Ayah Name of Company : passed away 5Y ago
(Nama Perusahaan)
No.Telp / HP :-

Mother's Name : Nurbaida Occupation (Pekerjaan) : Housewife

Nama Ibu Name of Company :-
(Nama Perusahaan)
No.Telp / HP : 082389274651
Husband's/Wife's (Maiden) Name (including aliases) Occupation (Pekerjaan) : -
Nama Suami/Istri (Termasuk Alias) : - Name of Company :-
(Nama Perusahaan)
No.Telp / HP :-
No. of Son(s) :- No. of Daughter(s) :-
Jumlah Anak Laki-laki Jumlah Anak Perempuan
Age Respectively(Umur) : - Age Respectively(Umur) : -

No Name of the Next of Kin Relationship Occupation Address (Alamat) Phone No

(Nama Saudara/sanak famili) (Hubungan) (Pekerjaan) (No HP)
1 Nurmala Fajriati Siblings Housewife Batam 082173826184
2 Tetti Eka Dharma Siblings ASN Solok 081363073468
3
4
5
6
7
8

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3. SCHOOLS School/Institution Pri/Sec Highest Standard Passed Year of Year of

ATTENDED Nama Sekolah etc (Certificate or Diploma) Entrance Leaving
Tahun Masuk Tahun Selesai
State schools/colleges SDN 20 Koto Gaek Passed 1983 1988
attended indicating
whether Primary, SMPN 3 Gunung Talang Passed 1988 1992
Secondary, Pre-Univer
sity etc. SMAN 1 Gunung Talang Passed 1992 1995

Sebutkan nama Universitas Riau Bachelor Passed 2007 2011

tingkatan sekolah Kepulauan
nya (SD,SMP,SMA
Universitas

4. COURSE NAME OF COURSE Year of Year of

ATTENDED Nama Kursus Tambahan Entrance Leaving
Kursus Tambahan Thn. Masuk Thn. Selesai

Pelatihan Pelatihan Pajak & Beacukai 29/9/04 30/9/04

Diklat Diklat Pajak & Kepabeanan 27/9/05 30/9/05

every seminar/briefing for
Seminar/briefing Seminars held by Customs on export/import regulation rev of regulation

in house training Inhouse training / course PT Foster

(leader course,ISO 14001internal auditor,ISO T/S internal
auditor,horenso.poka yoke) (certificate of origin which is
General System preferences
stated in certificate that exported goods are originating from
Seminar exporter country) PEMKO Batam

5. LANGUAGE SKILL Indonesian English Japanese Mandarin

(Kemampan Berbahasa) (Bahasa Indonesia) (Bahasa Inggris) (Bahasa Jepang) (Bahasa Mandarin)
Written
(Menulis) Advanced Advance mid
Spoken
(Berbicara) Advanced Advance mid

6. PROFESSIONAL experience to handle export - import, leadership,computer skill,quickly learn,

QUALIFICATIONS communicative, able to work as part of team.
Keahlian yg dimiliki

7.
DRIVING
LICENCE, ETC TELEX YES NO
Telex
Surat Izin
Mengemudi, dll
Knowledge of Accounts MS Office
Pengetahuan tentang Akunting MS Office
YES NO YES NO

Driving Licence International class

Jenis SIM yg dipunyai Kelas International

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8. EMPLOYMENT DATE Name & Full Address Reasons for Leaving

HISTORY Tanggal of Employer & Name each Employer, and
Pengalaman FROM TO of immediate Superior Position held by you Last drawn salary
Kerja Dari Sampai Nama Perusahaan dan Alamat Posisi yang anda pegang Alasan Keluar, dan
serta Atasan Langsung gaji terakhir
Fill in the full 6/5/96 27/8/19PT Foster Electric Indonesia Shipping Executive Rp. 6,300.000.00
particulars of all Kawasan Industri Batamindo
your employment Jalan Beringin, lot.3
since leaving Muka Kuning, Batam
school/University
and any period Manager : Mr. Martin Ling
of unemployment

Diisi dgn lengkap

pengalaman kerja 27/9/19Now Go back to my home town (solok,SUMBAR)
semenjak selesai staying at home take care of my mom & niece
dari sekolah/Per
guruan tinggi dan
juga waktu selama
tidak bekerja
(Pengangguran)

9. Salary Expected Rp. 8,000,000.00 Date of commencement : immediatelly

Gaji yg diinginkan Tanggal Mulai Bekerja

10. Scholarships/
Prizes/Awards -
Beasiswa/Piagam
Penghargaan
11. Extra-Curricular
Activities Zumba,Aerobic
Kegiatan
Extra-Curriculer
12. Hobbies and Rec
reational Activities Sport, reading, music listenig
Hobbi dan kegiat-
an rekreaksi

13. Physical Disability

Impairment or seri -
ous Illness
Gangguan fisik atau
pernah menderita
penyakit serius

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14. Have you everbeen

convicted before No, I have never been
for any offences ?
(If so give details)

15. PREVIOUS Have you previously applied for employment in MMI before ? No, I have't yet
APPLICATIONS (Apakah sebelumnya anda pernah melamar pekerjaan sebelumnya ke MMI? )
Lamaran terdahulu (If YES, State position(s) applied for and date(s) of application)
(Jika ya, sebutkan posisi yang dilamar dan tanggal lamarannya)

16. CHARACTER 1. Name (nama) : PON BENG HOI Address Mess PT Foster
REFEREES Occupation (Pekerjaan) : PD at PT Foster Electric ind
Referensi Seseorang No. of Years Known : 2005 Phone Number
Give particulars Tahun kenal 0811696669
of two persons 2. Name (nama) : Address Batam Center
who know you well Occupation (Pekerjaan) : IT & innovation Manager
Berikan 2 orang yang No. of Years Known : 2005 Phone Number
anda kenal baik Tahun kenal 08556570080

17. Fill in below full particulars of all your immediate relative in MMI

Sebutkan nama yang anda kenal di MMI

Nama Relationship Grade Name of Company and Phone number

No
Name Hubungan Jabatan Nama Perusahaan dan Nomor telephone

1. - - - -

2. - - - -

18. For Emergency case only (please fill in below full particulars) :
Khusus kasus emergency (Silahkan isi kolom di bawah ini dengan lengkap):
Nama Relationship Address
Telp / HP
Name Hubungan Alamat
Nurmala Fajriati Siblings Kav. Sagulung Baru Blok K-45 082173826184

19. DECLARATION TO BE SIGNED BY APPLICANT

I Hereby certify that the information contained in this form is correct and I understand that the company may terminate
my services at any time if any of the above information is found to be false.
Saya menyatakan bahwa data yang diisi semua adalah benar, dan saya mengerti apabila ada kebohongan dengan data saya,
Perusahaan dapat memberhentikan saya setiap saat, tanpa kompensasi apapun.
I understand that a medical examination is a condition precedent to selection for appointment and I express my willingness to
be somengerti
Saya examinedbahwa
(if required) and to furnish
pemeriksaan the adalah
kesehatan CompanyhalDoctor with full
yang utama details
dalam of mypenerimaan
seleksi previous medical history.
dan sayabersedia untuk mela
kukan pemeriksaan (jika dibutuhkan) untuk melengkapi data oleh dokter perusahaan mengenai kesehatan masa lalu saya.

Date Jan, 14th 2020 Signature Heppi Elpa Zamli

Tanggal Tanda Tangan

Applicants should attach copies of certificates and testimonials relevant to this application.
20. Original should not be sent at this stage. Should you have other relevant information kindly use a seperate
sheet of paper.
Pelamar harus melampirkan copy dari certificate dan surat pengalaman kerja yang berhubungan dgn form ini.
Document yang asli jangan dikirim. Apabila anda mempunyai informasi yang berhubungan, gunakan kertas yang lain.

Completed application to be returned to:

HUMAN RESOURCE DEPARTMENT
PT. MES MACHINERY INDONESIA
Jl. Brigjen Katams, KM.18, Kel. Tj. Uncang
Kec. Batuaji, Kota Batam

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 Jl. Brigjend Katamso, KM.18, Kel. Tj. Uncang, Kec. Batuaji, Kota Batam,
Kepri - Indonesia

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