SCANDINAVIAN IBS SDN BHD (1193908-H)

P371, LORONG PERINDUSTRIAN BUKIT MINYAK 21,

TAMAN PERINDUSTRIAN BUKIT MINYAK,
(PENANG SCIENCE PARK)
14100 SIMPANG AMPAT, PENANG, MALAYSIA
Tel: +604-5062940 Fax: +604-5062942

EMPLOYMENT APPLICATION FORM Position Apply

All information disclosed shall be treated with strictest confidence.

ID On Board Date Recommended by Locker No. Safety Shoes Uniform

Emp ID & Name

PERSONAL DETAILS/BUTIRAN PERIBADI

Full Name (as in
NRIC/Passport)
(Nama Penuh
Mengikut K/P)
NRIC (New) Date of Birth Age
– – (Umur)
(No. K/P Baru) (Tarikh Lahir)
Gender Male Female Race Religion
(Jantina) (Lelaki) (Perempuan) (Bangsa) (Agama)
Mobile Tel No. Email
(No. Telefon) (Email)
Marital Status Single Married Divorced No. of Child
(Taraf Perkahwinan) (Bujang) (Berkahwin) (Bercerai) (Bilangan Anak)
Bank Account No. Bank Name
(No. Akaun) (Nama Bank)
EPF No. Income Tax No.
(No. KWSP) (No. Cukai Pendapatan)
Height Weight
cm (Berat) kg
(Tinggi)
Correspondence/
Residential Address
(Alamat Surat Postcode
Menyurat) (Poskod)

FAMILY PARTICULARS/BUTIRAN AHLI KELUARGA

Full Name Relationship Age Designation/School
(Nama Penuh) (Hubungan) (Umur) (Pekerjaan/Sekolah)

*Including Spouse & Child (Termasuk Pasangan & Anak)

1
EDUCATION BACKGROUND/LATAR BELAKANG PENDIDIKAN
Year (Tahun)
Level of Education Institution Name Qualification Major & Specialisation
(Peringkat Pengajian) (Nama Institusi) (Kelulusan) (Bidang) From To
(Dari) (Hingga)
1. University
(Universiti)
2. College/ Polytechnic
(Kolej/Politeknik)
3. Secondary School
(Sekolah Menengah)

EMPLOYMENT HISTORY/LATAR BELAKANG PEKERJAAN

1. Name of Employer Last Job Title Basic Salary Year
(Nama Majikan) (Jawatan Terakhir) (Gaji Pokok) (Tahun)
Start End Start End
(Mula) (Tamat) (Mula) (Tamat)
RM RM MM/YY MM/YY
Brief description of duties and responsibilities during employment.
(Penerangan ringkas tentang tugas dan tanggungjawab semasa bekerja)

Reason of Leaving
(Sebab Berhenti Kerja)
2. Name of Employer Last Job Title Basic Salary Year
(Nama Majikan) (Jawatan Terakhir) (Gaji Pokok) (Tahun)
Start End Start End
(Mula) (Tamat) (Mula) (Tamat)
RM RM MM/YY MM/YY
Brief description of duties and responsibilities during employment.
(Penerangan ringkas tentang tugas dan tanggungjawab semasa bekerja)

Reason of Leaving
(Sebab Berhenti Kerja)

EMERGENCY CONTACT/HUBUNGI SEMASA KES KECEMASAN

Full Name
(as in NRIC/Passport)
(Nama Penuh Mengikut K/P)
NRIC (New) Mobile Tel No. Relationship
(No. K/P Baru) (No. Telefon) (Hubungan)

Correspondence/
Residential Address
(Alamat Surat Menyurat) Postcode
(Poskod)

Expected Monthly Salary Negotiable

(Gaji Bulanan Yg Dijangka) (Boleh Berunding) YES NO
Earliest Join Date Resignation Notice
(Tarikh Terawal Lapor Diri) (Tempoh Notis)

2
OTHERS/LAIN-LAIN
1. Do you currently involved or have history with the use of prohibited substances? YES NO
(Adakah anda terlibat atau pernah terlibat dalam kes berkaitan penyalahgunaan bahan terlarang?)
2. Have you ever been convicted of a crime/jailed? YES NO
(Adakah anda pernah disabitkan dengan jenayah/dipenjara?)
3. Are you currently declared bankrupt or blacklisted by any local or international bank?
(Adakah anda kini diisytiharkan muflis atau disenaraihitam oleh mana-mana pihak bank tempatan atau YES NO
bank antarabangsa?)
4. Are you able to work long hours? YES NO
(Adakah anda berupaya berkerja lebih masa?)
5. Have you ever absconded or being terminated from any position? YES NO
(Pernahkah anda menghilangkan diri atau diberhentikan kerja bagi mana-mana jawatan?)
6. Have you ever suffered from any serious/chronic illness? YES NO
(Adahkah anda mengalami sebarang penyakit yang serius/kronik?)
7. Have you ever suffered from any serious mental illness? YES NO
(Adahkah anda mengalami sebarang penyakit mental yang serius?)
8. Are you required to take any long-term medication? YES NO
(Adakah anda perlu mengambil apa-apa ubat secara berpanjangan?)
9. Are you pregnant (female only)? How many months?____________________ YES NO
(Adakah anda mangandung (wanita sahaja)? Berapa bulan? ________________________)
10. Do you own any OKU card? If yes, please state card no.__________________ YES NO
(Adakah anda merupakan pemegang kad OKU? Jika ya, sila nyatakan no. kad______________)
11. Have you ever had accident that resulted in broken/fractured limb or suffer limb extension?
(Adakah anda pernah mengalami kemalangan yang mengakibatkan anggota badan patah/retak YES NO
atau menjalani pembedahan penyambungan anggota badan?)
12. Are you able to differentiate colours clearly?
YES NO
(Adakah anda berupaya membezakan warna dengan jelas?)
13. Are you able to differentiate sound clearly?
YES NO
(Adakah anda berupaya membezakan bunyi dengan jelas?)
14. Do you have illness that require regular check ups?
Illness:__________________________________________
YES NO
(Adakah anda mempunyai penyakit yang memerlukan pemeriksaan tetap?)
Penyakit: ________________________________________
15. Do you have spinal problems that unable lift heavy items?
YES NO
(Adakah anda mempunyai masalah tulang belakang yang menghalang angkat barang berat?)
16. Do you have joint/nerve/knee related problem(s)?
YES NO
(Adakah anda mempunyai masalah berkaitan sendi/saraf/lutut?)
17. Do you have respiratory related problem(s)? YES NO
(Adakah anda mempunyai masalah berkaitan pernafasan?)
18. Do you feel dizzy when being at high place [2m-5m from floor level]?
YES NO
(Adakah anda berasa pening/pitam ketika berada di tempat tinggi [2m-5m dari paras lantai])?
19. Are you able to work in shift?
YES NO
(Adakah anda boleh bekerja secara syif?)

I hereby declare that all information provided by me in this form is true and correct to the best of my knowledge and belief. If any
false and inaccurate information given in this application will render any subsequent employment contract null and void. If being
appointed, I agree to be transferred to any branch or group of the companies throughout Peninsula Malaysia. I also agree to allow
the Company access to my medical records and consent to have my earnings being paid via bank transfer or cheque, where
applicable.

Signature Date
Signature of the Person Submitting this Form DD MM YY

3
FOR OFFICE USE PURPOSE
INTERVIEWED BY
Interviewer Signature

Designation Date

REMARKS/RECOMMENDATIONS

REJECT

KIV

ACCEPT

Status : Permanent / Contract

Position Offered : …………………………………………………..
Station : …………………………………...…………….
On Board Date : …………………………………………………..

Remuneration:
Monthly Basic Pay : RM

Safety Allowance : RM 100.00 (Applicable to Production Staff ONLY)

Attendance Allowance : RM 100.00 (Applicable to Production Staff ONLY)

Others : RM

Approved by: Date

Name and Signature of HR manager DD MM YY