No 77A & 79A, 1st Floor, Jalan Batai Laut 3

Taman Intan, 41300, Klang, Selangor

Recent Photograph
APPLICATION FORM

The information provided in this form will be kept strictly confidential.

Position Applied For

Salary Expected
Date Applied

PERSONAL PARTICULARS

Name As Per NRIC

(Mr/Mrs/Ms/Mdm) :

Postal
Permanent Address
Address

NRIC No (NEW) Age

NRIC No (OLD) Gender/Sex

Date of Birth Nationality

Place of Birth Race

Marital Status Religion

No of Children (if any) E-Mail

Facebook Email Instagram

Tel No (H) : (O) : (H/P) :

Any Insurance Policy

Language (Written): (Spoken):

FAMILY INFORMATION (Parent, Brothers/Sisters, Spouse, Children)

Name Relationship Age Occupation Place of Work

 EDUCATION HISTORY

Level Name of Secondary / College / University From To Qualification

Secondary

College

University

Other

Courses

EMPLOYMENT HISTORY

Employment
Company / Place Salary Position Job Description Reason for Leaving
Period

From :

To :

From :

To :

From :

To :

From :

To :

From :

To :

REFERENCES

Name Designation Yrs Known Company / Address / Contact No.

 GENERAL DECLARATIONS
Answer the following declarations:

Do you have any pre-existing health conditions that may affect your work performance? Yes No
Examples include but not limited to diabetes, irritable bowel syndrome, epilepsy, high blood
pressure, lameness, stammering etc.
If Yes, please state:

Have you had any major operations done before? Yes No

If Yes, please state:

Are you declared bankrupt or have declared bankruptcy in the past? Yes No

Have you ever been charged with or convicted of a criminal offence in a Court of Law? Yes No

For female candidates, are you currently pregnant? Yes No

ANY ADDITIONAL INFORMATION

Please state any additional information that you wish to mention that may assist in your application.

DECLARATION OF CANDIDATE

I hereby declare that all particulars provided are true to the best of my knowledge and that I have not suppressed any material facts. If, after
engagement of employment, it is found that I have made a false declaration, misrepresentation or omission of facts on this form, the
Company reserves the right to terminate my service without any notice or compensation.

Signature of Applicant: Witnessed By:

Name: Name:
IC No: IC No:
Date: Date:
Name: Name:
FOR OFFICE USE ONLY
INTERVIEWER: SOURCE:

ITEM DATE REMARK

1st Interview
Job Orientation
Documentation
Item Attached/Provided
Resume/CV Yes No
2x Passport Sized Photo Yes No
Photocopy of IC Yes No
Proceed with Career Choice Yes No