Office Address: Phone +62-21 8082-4000

Ratu Prabu II Building, Fax +62-21 8082-4002

6th - 9th Floor WWW.medcoenergi.com
Jl. TB. Simatupang Kav.1B
Jakarta 12560 Indonesia

INTERNSHIP APPLICATION FORM DATE: ___________________

Applying for Internship for ___________________ Department /Function

A. PERSONAL DATA

Name

Permanent Address

Province : Postal Code :

Phone Number Home Phone Number :

Cellular Phone Number :

Email Address

Identity Card Number (KTP)

Place and Date of Birth (M/ D/ Y) Place of birth :

Date of birth :

Gender [ ] Male [ ] Female

Marital Status [ ] Single [ ] Married

Indonesian Citizen [ ] Yes [ ] No

B. EDUCATION DATA

SCHOOL PRINT SCHOOL NAME DATE (from to) MAJOR OR GRADUATED GPA
AND CITY COURSE
TYPE

SR. HIGH N/A

SCHOOL

ACADEMY/
UNIVERSITY

COURSES INFORMATION

COURSE NAME INSTITUTION YEAR

1
Office Address:
Ratu Prabu II Building,
6th - 9th Floor
Jl. TB. Simatupang Kav.1B
Jakarta 12560 Indonesia
Phone +62-21 8082-4000
Fax +62-21 8082-4002
WWW.medcoenergi.com

A. FOREIGN LANGUANGE SKILL

(Please specify either in Fair or Fluent or Limited and if you have TOEIC or TOEFL Score within the
latest 2 years - please specify the score)

LANGUAGE SPOKEN READING WRITTEN

B. PRE-INTERVIEW QUESTIONS

1. How do you know about the internship program in Medco E&P Natuna:
[ ] Medco E&P Indonesia Web
[ ] Medco E&P Natuna Employee - Name of referral source __________________________________

[ ] Others please specify ________________________________________

2. Do you have any relatives or friends who work as Medco E&P Natuna employee or Contractor employee
for Medco E&P Natuna?
[ ] Yes [ ] No

If YES please fill in detail information below, you can mention more than one who have significant
relationship with you.

Name : _____________________________

Relationship : _____________________________
(any kind of significant relationship including but not limited to siblings,
in law, almamater, neighbor, others)

Department or Division : _____________________________

Work Location : _____________________________

Work For :[ ] Medco E&P Natuna

[ ] Contractor Company ( please specify _________________________)

2
Office Address:
Ratu Prabu II Building,
6th - 9th Floor
Jl. TB. Simatupang Kav.1B
Jakarta 12560 Indonesia
Phone +62-21 8082-4000
Fax +62-21 8082-4002
WWW.medcoenergi.com

3. Do you have any relatives who works as Government Official or works for Government Own Company
(BUMN)?
[ ] Yes [ ] No

Government Officials include individuals who hold official government position (legislative, executive,
administrative or judicial); individuals who exercise public functions for or on behalf of a country or a public
agency/ enterprise; officers, employees, or agents of any government, government agency, or government
instrumentally including government-owned or government-controlled companies; officials and agents of
political parties; candidates for political office; close relatives of any of the above.

If YES please fill in detail information below, you can mention more than one who have significant
relationship with you.

Name : _____________________________

Relationship : _____________________________
(any kind of significant relationship including but not limited to siblings,
in law, almamater, neighbor, others)

Title (complete title) : _____________________________

Department : _____________________________

Government Institution or : _____________________________

Government Own Company

Is there any conditions where your relatives as a Government officials could be involved in any way in
COPIs business or activities in Indonesia
[ ] Yes [ ] No

If YES please explain about it

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____

DECLARATION I declare that to the best of my knowledge and belief all statements in this internship
application form are true.

__________________________________ ______________________
(E-Signature of Applicant) (Date)