Manual Title

Form name
Form No.

: Human Resources Manual

: Recruitment Application Form
: AOS-04-01-F002-TBA

Series No:
Level 3

Issued By:
HRGA

Manual Number:
AOS-04-01
Issue Date:
23-May-12
Rev. Date:
N/A
Rev. No:
00

Approved By:
General Manager

PRIVATE & CONFIDENTIAL

PERSONAL DETAILS DATA PRIBADI

Full Name
Nama Lengkap
Place / Date Of Birth
Tempat / Tanggal Lahir
Nationality
Kebangsaan
Blood Type
Golongan Darah
Marital Status
Status Pernikahan
Religion
Agama

RONY PRAYITNO SIMEON

BOGOR, 17TH DECEMBER 1980
INDONESIA
[ ]
[ ]
[ ]

A
Single
Lajang
Moslem
Muslim

ID Card Number
Nomor KTP

2171071712809003

Passport Number
Nomor Paspor

A 3526831

Driving License Number

Nomor SIM

801212211298

Jamsostek Number
Nomor Jamsostek
Indonesia Tax Number
NPWP
Clothe Size
Ukuran Baju

[ ]
[ ]
[ ]

B
Married
Menikah
Christian
Kristen

12040693165
68.052.269.5-215.000
XXL

[ ]
[ ]
[ ]

AB

[ ]

Widower
Duda / Janda
Catholic
[ ]
Katolik
Date of Expiry
Berlaku Hingga
Place of Issue
Dikeluarkan Di
Date of Expiry
Berlaku Hingga
Place of Issue
Dikeluarkan di
Date of Expiry
Berlaku Hingga
Place of Issue
Dikeluarkan di
Date of Issue
Tanggal Terbit
Date of Issue
Tanggal Terbit
Shoe Size
Ukuran Sepatu

Hindu
Hindu

[ ]

Buddha
Budha

17 DECEMBER 2017
KOTA DEPOK
14 NOVEMBER 2017
DEPOK
17 DECEMBER 2018
KOTA DEPOK
11/2012
14 JANUARY 2009
9 / 43

PERSONAL CONTACT KONTAK PRIBADI

Address
Alamat
Home Telephone Number
Nomor Telepon Rumah
Mobile Number
Nomor Telepon Selular
Email Address
Alamat Email

Pesona Khayangan Juanda Blok BC No.18

Post Code
Kode Pos

16411

NA
+6281288499710
ronysimeon@yahoo.com

LEISURE INTEREST (HOBBY) KEGIATAN WAKTU LUANG (HOBI)

Reading, Swimming and Watch movie

HRGA Department

Recruitment Application Form

1/8

Manual Title
Form name
Form No.

: Human Resources Manual

: Recruitment Application Form
: AOS-04-01-F002-TBA

Series No:
Level 3

Issued By:
HRGA

Approved By:
General Manager

Manual Number:
AOS-04-01
Issue Date:
23-May-12
Rev. Date:
N/A
Rev. No:
00

PRIVATE & CONFIDENTIAL

FAMILY DETAILS DATA KELUARGA

Spouse
Suami / Istri
Place / Date of Birth
Tempat / Tanggal Lahir
Nationality
Kebangsaan

JUNIKE CHRISTIEN KODOATIE

SOROWAKO, 10 JUNE 1978
INDONESIAN

ID Card Number
Nomor KTP

2171105006789011

Passport Number
Nomor Paspor

A 0271299

CHILDREN
ANAK
First
Anak-1
Second
Anak-2
Third
Anak-3

Date of Expiry
Berlaku Hingga
Place of Issue
Dikeluarkan Di
Date of Expiry
Berlaku Hingga
Place of Issue
Dikeluarkan Di

Full Name
Nama Lengkap

Place / Date of Birth

Tempat / Tanggal Lahir

10 JUNE 2018
KOTA DEPOK
26 APRIL 2016
BATAM

Gender
L/P

Education Level
Pendidikan

WILLIAM WICAKSONO SIMEON

BRUNEI, 28 AUG 2012

NA

WILBERT WIBISONO SIMEON

DEPOK, 11 JAN 2014

NA

EMERGENCY CONTACT KONTAK DARURAT

Full Name
Nama Lengkap
Relationship
Hubungan
Address
Alamat
Home Telephone Number
Nomor Telepon Rumah
Mobile Number
Nomor Telepon Selular
Email Address
Alamat Email

JUNIKE CHRISTIEN KODOATIE

ISTRI
Pesona Khayangan Juanda Blok BC No.18

Post Code
Kode Pos

16411

NA
+6281317974211
Jc_kodoatie@yahoo.com

FORMAL EDUCATION PENDIDIKAN FORMAL

School / Academy / University

HRGA Department

Major

Recruitment Application Form

Degree

Grade

Year

2/8

Manual Title
Form name
Form No.

: Human Resources Manual

: Recruitment Application Form
: AOS-04-01-F002-TBA

Series No:
Level 3

Issued By:
HRGA

Manual Number:
AOS-04-01
Issue Date:
23-May-12
Rev. Date:
N/A
Rev. No:
00

Approved By:
General Manager

PRIVATE & CONFIDENTIAL

Sekolah / Akademi / Universitas

Jurusan

Gelar Pendidikan

IPK

Tahun

Gadjah Mada University

Physics Engineering

Sarjana Teknik

3.38

2006

TRAINING / COURSE PELATIHAN / KURSUS

Institution

Subject

Certification (Number)

Score

Year

Nama Penyelenggara

Nama Pelatihan / Kursus

Sertifikasi (Nomor)

Nilai

Tahun

AINSCOUGH UK

APPOINTED PERSON

9985-21387

NA

2013

JTN TECHNICAL SERVICES

OPITO COMPETENCE ASSESSOR

63729018170215JTN496

NA

2014

G20372/1

NA

2013

G20372

NA

2013

NA

2013

NA

2010

NA

2011

NA

2011

NA

2014

NA

2014

NA

2014

NA

NA

2011

NORTH SEA LIFTING UK

NORTH SEA LIFTING UK

NORTH SEA LIFTING UK

LIFTING EQUIPMENT
ENGINEER ASSOCIATION UK
LIFTING EQUIPMENT
ENGINEER ASSOCIATION UK
LIFTING EQUIPMENT
ENGINEER ASSOCIATION UK
LIFTING EQUIPMENT
ENGINEER ASSOCIATION UK
LIFTING EQUIPMENT
ENGINEER ASSOCIATION UK
LIFTING EQUIPMENT
ENGINEER ASSOCIATION UK
SILVER DOT UK

HRGA Department

COMBINED RIGGING & LIFTING

AND BANKSMAN/SLINGER
ADVANCED RIGGING & LIFTING
TECHNICAL SUPPORT
E-LEARNING FOR LIFTING TA:
1. BP Criteria,
2. UK, US and Norwegian Regulation
3. Lift Planning
4. Rigging Loft Management
5. Equipment Certification
6. Gantry Cranes and Overhead
Cranes
7. Forklift Operation
8. Winches and Pulling Operations
9. Cargo Carrying Unit and Cargo
handling
10. Dropped Object
11. Cranes onshore / Offshore and
Marine
12. Man Riding and Personnel
Transfer
13.Crane
FMEA,
FAT
and
Commisioning
14. Helicopter Lifting
15. Subsea Lifting
16. Self Verification, Assurance and
Audit
LIFTING EQUIPMENT GENERAL
DIPLOMA
LIFTING MACHINE MANUAL
DIPLOMA
LIFTING MACHINE POWER
DIPLOMA
RUNWAY & LIGHT CRANE
STRUCTURES DIPLOMA
OVERHEAD TRAVELLING &
PORTAL CRANE DIPLOMA
OFFSHORE CONTAINERS
DIPLOMA
DROP OBJECT PREVENTION
SCHEME (DROPS) TRAINING FOR
TRAINER

1462013-01-30
1462013-01-30
1462013-01-31
1462013-02-05
1462013-02-09
1462013-02-06
1462013-02-10
1462013-02-07
1462013-02-08
1462013-02-09
1462013-02-26
1462013-03-02
1462013-05-02
1462013-06-13
1462013-06-30
1462013-07-03

Recruitment Application Form

3/8

Manual Title
Form name
Form No.

: Human Resources Manual

: Recruitment Application Form
: AOS-04-01-F002-TBA

Series No:
Level 3

Issued By:
HRGA

Manual Number:
AOS-04-01
Issue Date:
23-May-12
Rev. Date:
N/A
Rev. No:
00

Approved By:
General Manager

PRIVATE & CONFIDENTIAL

KPDM MIGAS

CRANE INSPECTOR

286/IPA/MIGAS/2009

Very Good

2009

IKBAL M YOS

WELDING INSPECTOR

375/WI-XV/X/2008

Satisfactory

2008

IKBAL M YOS

ASNT LEVEL II RTFI

1093/RI-II/SKB/2009

NA

2009

DB SCHOOL OF NDT

ASNT LEVEL II MT

MT-1042

85.5

2010

DB SCHOOL OF NDT

ASNT LEVEL II PT

PT-1042

88.1

2010

DB SCHOOL OF NDT

ASNT LEVEL II UT

UT-PP-11111

86.6

2011

TANLA TESCOR WELINDO

ASNT LEVEL II ECI

1446/ET-II/SU/2011

NA

2011

PT RIGSPEK PERKASA

WIRE ROPE SOCKETING

1467

NA

2010

PT RIGSPEK PERKASA

WIRE ROPE INSPECTOR

1468

NA

2010

PT RIGSPEK PERKASA

WIRE ROPE INSPECTOR

1578

NA

2010

LEAD AUDITOR ISO 9001 IRCA

REGISTERED

ON PROGRESS

NA

2015

SGS INDONESIA

EXPERIENCE & ACHIEVEMENTS PENGALAMAN & PRESTASI

Best 20 % Graduate at the Faculty of Engineering Gadjah Mada University, Indonesia
3rd Rank of Crane Inspector MIGAS 11th enrollment
Lifting Equipment Engineer Association Lifting Gear General Diploma, Pass with Distinction (96 % Pass)
Lifting Equipment Engineer Association Lifting Machine Power Diploma, Pass with Distinction (80 % Pass)
Passed BP Level 4 competency for Regional Lifting TA position
Increase BP Aspac Lifting Performance as following KPI:

Safety trend were improving in quantity and quality compare to HiPo Forklift brake failure on 2012

Lifting plan generated were increased by number and quality. We could see it from increasing of lifting categorisation
to the higher level based on risk assessment which also indicate the skills of the site lifting team to identify the
hazard were improved

No Lifting related incident from last TAR 5 vs 4 lifting incident on TAR 4 which means lesson learn and improvement
were identified and implemented

Log book system already been implemented in Tangguh to achieve systematic competency development and
targeted by end 2015 all lifting crew achieved benchmarking competency acknowledge by BP and Industrial practices
such as Rigger would be OPITO Stage 3 or ECITB Level 3 moving Load or EAL CoC Level 2 A + B

HAVE YOU EVER BEEN IMPRISONED

Apakah Anda pernah berurusan dengan hukum / penjara
(Please specify if you have any)
(Beri keterangan bila jawaban anda Ya)

[ ]

Yes Ya

HEALTH CONDITION (Please specify if you have any)

KONDISI KESEHATAN (Beri keterangan bila jawaban anda Ya)
Inherent Illness? Penyakit keturunan?
[Yes]:

HRGA Department

Recruitment Application Form

[ ]

Yes Ya

[ ]

No Tidak

[ ]

No Tidak

4/8

Manual Title
Form name
Form No.

: Human Resources Manual

: Recruitment Application Form
: AOS-04-01-F002-TBA

Series No:
Level 3

Issued By:
HRGA

Approved By:
General Manager

Manual Number:
AOS-04-01
Issue Date:
23-May-12
Rev. Date:
N/A
Rev. No:
00

PRIVATE & CONFIDENTIAL

Physical Disease? Cacat?

[Yes]:

[ ]

Yes Ya

[ ]

No Tidak

Did you ever have a disease that need long term recovery?
Pernah mengalami penyakit menahun?
[Yes]:

[ ]

Yes Ya

[ ]

No Tidak

Others Lain lain

[Yes]:

[ ]

Yes Ya

[ ]

No Tidak

[ ]

Mild Drinker
Sesekali

[ ]

Drinker
Sering

Do you consume alcoholic drink?

Mengkonsumsi minuman keras?

[ ]

[ ]

Yes
Ya

No
Tidak

MEMBERSHIP OF PROFESSIONAL ASSOCIATION

ANGGOTA ORGANISASI / PERKUMPULAN

Year Attended / Attending

Tahun (dari-hingga)

LIFTING EQUIPMENT ENGINEER ASSOCIATION

2009 Now

IKATAN AHLI TENAGA MIGAS INDONESIA BRUNEI CHAPTER

2011 - 2012

PRESENT EMPLOYMENT PEKERJAAN SEKARANG

Employer
Nama Perusahaan

PT INSPEKTINDO SINERGI PERSADA

Address of Employer
Alamat Perusahaan

Mall Mobil Building, JL. TB Simatupang Kav 1-S

Job Title
Jabatan

Advisor for Lifting Contract and Trainer

Working Period
Periode Kerja

April 1st 2015 - Now

Salary (Compulsory)
Gaji (Wajib Diisi)

Depend on the Job

Resignation Notice Period

Batas Waktu Pemberitahuan Berhenti Bekerja

1 Month notice

[ ] Gross

[ ] Net

Duties
Tugas
1.Develop lifting procedure for Inspection, Maintenance and Lifting Operation for tender at Oil and Gas Company
2.Conduct training as per LEEA, OPITO and ECITB scheme for Lifting Inspectors, Lifting Supervisor, Lifting Engineer, Rigger, Crane
Operator, banksman, etc.

HRGA Department

Recruitment Application Form

5/8

Manual Title
Form name
Form No.

: Human Resources Manual

: Recruitment Application Form
: AOS-04-01-F002-TBA

Series No:
Level 3

Issued By:
HRGA

Approved By:
General Manager

Manual Number:
AOS-04-01
Issue Date:
23-May-12
Rev. Date:
N/A
Rev. No:
00

PRIVATE & CONFIDENTIAL

PREVIOUS EMPLOYMENT (from most recent post)

PEKERJAAN SEBELUMNYA (Dimulai dari tahun terbaru)
Working Period

Employer, Address & Phone

Number

Job Title / Duties

Last Salary

Reason of Leaving

Periode Kerja

Perusahaan, Alamat & Telepon

Jabatan / Tugas

Gaji Terakhir

Alasan Berhenti

Oct 2012 Mar 2015

BP Berau

Regional Deputy Lifting TA

IDR 65,000,000

Employee Reduction

Nov 2011 Oct 2012

Brunei Shell Petroleum

Lifting Surveyor

BND 6,500

Accepted By BP

Jul 2009 Nov 2011

PT Rigspek Perkasa

Inspection & Testing Manager

IDR 25,000,000

Accepted By BSP

REFERENCE IN KS DRILLING / ATLANTIC OILFIELD SERVICES (AOS)

REFERENSI DI LINGKUNGAN KS DRILLING / ATLANTIC OILFIELD SERVICES (AOS)
Name
Nama

No.

Position / Company
Jabatan / Perusahaan

Contact (Phone / E-Mail)

Kontak (Telepon / Surel)

REFERENCE REFERENSI
Please give the Name, Position / Company, Phone / Email, who are able and willing to give an opinion on your academic / professional
experience. One referee should be your present or past Employer.
Tuliskan Nama, Jabatan / Perusahaan, Telepon / Surel, yang dapat memberikan pendapat mengenai kemampuan / pengalaman
profesional Anda. Sedikitnya 1 orang referensi berasal dari Perusahaan yang sekarang atau sebelumnya.
No.

Name
Nama

Position / Company
Jabatan / Perusahaan

Contact (Phone / E-Mail)

Kontak (Telepon / Surel)

Kevin Boyle

SETA Lifting / BP International

+447825681385

Mohd Sani Abdullah

Lifting TA / Brunei Shell

Petroleum

+6738878771

Jannes Sibuea

Managing Director / Rigspek

Perkasa

+628127050231

ADDITIONAL INFORMATION KETERANGAN TAMBAHAN

HRGA Department

Recruitment Application Form

6/8

Manual Title
Form name
Form No.

: Human Resources Manual

: Recruitment Application Form
: AOS-04-01-F002-TBA

Series No:
Level 3

Issued By:
HRGA

Approved By:
General Manager

Manual Number:
AOS-04-01
Issue Date:
23-May-12
Rev. Date:
N/A
Rev. No:
00

PRIVATE & CONFIDENTIAL

POSITION APPLIED
JABATAN YANG DIINGINKAN
Expected Salary (Compulsory)
Gaji yang Diharapkan (Wajib Diisi)

LIFTING SPECIALIST
IDR 80,0000,000 / Month

[ ] Gross

[ ] Net

DECLARATION PERNYATAAN
I hereby declare that the information contained in this form is to the best of my knowledge correct. I understand that any willful
misstatement renders me liable to disqualification or instant dismissal if engaged.
Saya yang bertandatangan di bawah ini menyatakan bahwa seluruh keterangan pada formulir ini adalah benar dan dengan
tanggungjawab. Saya menyadari bila ada keterangan yang bertentangan (palsu) maka Saya bersedia untuk dikeluarkan dari Proses
Penerimaan Karyawan atau diberhentikan dari pekerjaan.

HRGA Department

Recruitment Application Form

7/8

Manual Title
Form name
Form No.

: Human Resources Manual

: Recruitment Application Form
: AOS-04-01-F002-TBA

Series No:
Level 3

Issued By:
HRGA

Approved By:
General Manager

Manual Number:
AOS-04-01
Issue Date:
23-May-12
Rev. Date:
N/A
Rev. No:
00

PRIVATE & CONFIDENTIAL

Signed Tanda Tangan:

HRGA Department

Date Tanggal:

Recruitment Application Form

8/8