JOB APPLICATION FORM

Application will be kept strictly confidential. Complete all entries in BLOCK LETTERS.
Insert “DNA” if question does not apply

POSITION APPLIED FOR

Retail assistant
1. _____________________________ OR 2. _____________________________

PERSONAL PARTICULARS
PHOTO
Lim Zu Yi
Full Name: _________________________________________________________

16,jalan lapangan raya 3,Taman lapangan raya ,31650

Address: ____________________________________________________________________
Ipoh,Perak
___________________________________________________________________________
060525080432
IC No: (New) _____________________________ (Old) _____________________
(Malaysia Identity Card No)

Home: ______________ 0185783881

Mobile: _______________ [email protected]
Email: ______________________
Cina Buddha
Gender: Male / Female Race: _________________ Religion: ____________________

Marital Status: Single / Married / Divorced / Widow

FAMILY PARTICULARS
Spouse Father Mother
Name
Lim Chee Fong Koo Lai Leng
IC No (New)

Designation Mechanic House wife

Employer’ Name LCF Mechanic

Employer’s
Address

0185783881
Contact No 0165536959 0165536746
文
Your Children
Name IC No (New) Gender Tax Relief
(Malaysia Identity Card No) (F/M) (Yes/No)
1.

2.

3.

4.

5.

PERSON TO CONTACT IN CASE OF EMERGENCY

Lim Chee Fong
Full Name: _________________________________________________________

16,jalan lapangan raya 3,taman lapangan raya,31650,Ipoh

Address: ____________________________________________________________________
Perak
___________________________________________________________________________

0165536959
Contact No: ___________________ Father
Relationship: ______________________

STATUTORY REFERENCES
KWSP No: ___________________________ PERKESO No: ____________________________

INCOME TAX No: _____________________ INCOME TAX Branch: _____________________

PAYROLL DETAIL
Bank Name: Public bank
______________________ Saving account
Account Type: ___________________________

Account No: ______________________

REFERRAL
If you were referred by a HTM Staff for this job application, please provide
HTM Staff Name: _________________________
HTM Staff IC No: _________________________
EMPLOYMENT RECORD
(List all work experience beginning with your present or last employment)
Last Draw Reason for
Name & Address of Employer From To Designation
Salary Leaving

REFEREES
Please name two person (not relatives) to who reference can be sourced

Name:__________________________________ Name:_____________________________

Designation: _____________________________ Designation: _______________________

Address:________________________________ Address:___________________________
_______________________________________ __________________________________
_______________________________________ __________________________________

Tel :___________________________________ Tel :______________________________

WORK EXPECTATION
Notice of resignation required for present employment ___________ month (s)

Willing to relocate: Yes / No

Current Salary: RM____________

Expected Salary: RM____________

EDUCATION BACKGROUND
School/College/University From To Certificates Obtained

LANGUAGE PROFICIENCY
(Proficiency is rated from 1 to 5, 5 being the highest level)
Other
Language English Malay Chinese
_____________
Spoken

Written

GENERAL INFORMATION
Have you ever been convicted for any criminal Yes No
offence in any Court of Law, whether in Malaysia or
overseas?
(If yes, please provide details)

Do you have any cases with the Labour Office / Yes No

Industrial Relations Office / Court
(If yes, please provide details)

Have you suffered from or are you currently suffering Yes No

from illness requiring regular medication
(If yes, please provide details)

Do you have any disabilities, physical or otherwise? Yes No

(If yes, please provide details)

Are you currently pregnant? (for female candidates) Yes No

(If yes, please provide details)

Do you have a member of your family/relative/friends Yes No

working with HTM Pharmacy Group?
(If yes, please provide details)
Full Name: IC No:
DECLARATION

1) I declare that the information given in this application is true and accurate. My employment may be based on
receipt of satisfactory information from former employers, schools and other references. Enclosed are copies
of my education / professional qualification certificate/ diploma / degree and /or appropriate
recommendation letters. If I am selected / employed, I will report to Human Resources Department the
changes or additions taking place from time to time. I understand that any misrepresentation of facts given
(including any uninformed changes) will be sufficient cause for denying employment or summary dismissal
from the company’s services if I have been employed.

2) I authorise the Group to conduct relevant background checks (including but not limited to financial check),
without liability, in consideration of my application for employment.

3) I agree that if a suitable position is not presently available within the Group, the Group may retain my
application and Personal Data for such period as the Group considers appropriate, in case a position that may
be suitable later becomes available.

Date: __________ Name: __________________________Signature: _______________

FOR COMPANY USE ONLY

SOURCE OF REFERRAL:
Newspaper / Company’s website / others (please specify):____________________________

Interviewed by: __________________________________Date: _______________________

Comments: _________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Further Interviewed by: ____________________________Date: _______________________

Comments: _________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Recommendation: SUCCESSFUL KIV REJECTED __________

Position Offered: _________________________

Date to commence: ___________________ Permanent Contract Others_________

During probation:

Salary: RM______________per month(s)

Allowance: RM ___________ per month(s) Probationary period: ________month(s)

Upon Confirmation:

Salary: RM______________per month(s)

Allowance: RM ___________ per month(s)

Reference Check: Yes No