Maid No. JFA163H 申 請 ⼈ 資 料Applicant's Information Sheet

Office use

姓名Name NURSIYATI

性別Gender Female

婚姻狀況Marital Status Married

國籍Nationality Indonesian

種族Race Javanese

膚⾊Complexion Brown

年齡Age 43

⽣肖Chinese Zodiac Horse

星座Horoscope Capricorn

⾝⾼Height 155 cm

體重Weight 60 kg

宗教教Religion Muslim

住址Address Kendal, Jawa Tengah, Indonesia

教教育Education Junior High

專修科⽬Course Taken

證書 / 執照Certificate / Licence (1) (2) (3)

以往受僱為僱為傭⼯紀錄Previous Employmentas a Domestic Helper(Summary)

⼯作地點Country (1) Hong Kong (2) Hong Kong (3) Hong Kong

年期Years (1) 4.0 years (2) 2.0 years (3) 1.2 years

擅⾧技能Special Abilities (1) Child Care (2) Baby Care (3) Cooking (4) Washing & Ironing

⾯試評價Interview Appraise

差Poor

平Average

中等Fair

好Good

個⼈表現Personality ( ) ( ) ( ) ( )✔儀容Facial Expression

( ) ( ) ( ) ( )✔家務Housework

( ) ( ) ( ) ( )✔照顧嬰嬰兒Baby Care ( ) ( ) ( ) ( )✔照顧兒童Child Care

( ) ( ) ( ) ( )✔照顧⾧者/傷殘Elderly/Disabled Care ( ) ( ) ( )✔ ( )

烹飪飪Cooking ( ) ( ) ( ) ( )✔英語會話Oral English

( )✔ ( ) ( ) ( )

廣東話Cantonese ( ) ( ) ( ) ( )✔普通話Mandarin ( )✔ ( ) ( ) ( )

其他語⾔Other Language -

備註Remarks

Worked in Hong Kong more than 7 years. She can take care of children, baby,do all house work and normal house keeping.以上資料由申請⼈提供及確認以上資料正確無訛，

若資料不符必須由申請⼈承擔責任

All information given above were provided & confirmed by applicant.Applicant is liable for all responsibilities for any false information

found.

Page 1

Maid No.JFA163H

以 往 受 僱僱 為為 傭 ⼯ 紀 錄Previous Employment as a Domestic Helper

(1) 僱僱主姓名Name of Employer Law Wai Song

僱僱主國籍Nationality Chinese

⼯作地點Country Hong Kong

主要⼯作Job Description ✔ 烹飪飪

Cooking ✔ 家務Housekeeping

醫務護理Nursing

⼯作期間Preiod

由From 26 Apr 1997

⾄To 26 Apr 2001

照顧Care of

嬰嬰兒Baby ✔ 兒童

Children⾧者Elderly

傷殘Disable

臥床Bedridden

寵物Pet

離職原因Reason Leaving

Finished Contract

成⼈Adult 2

兒童Child 2

年齡Age 4(G),6(G)

嬰嬰兒Baby

⾧者Elderly

傷殘Disabled

臥床Bedridden

(2) 僱僱主姓名Name of Employer Ngan Siu King

僱僱主國籍Nationality Chinese

⼯作地點Country Hong Kong

主要⼯作Job Description ✔ 烹飪飪

Cooking ✔ 家務Housekeeping

醫務護理Nursing

⼯作期間Preiod

由From 26 Jan 2005

⾄To 26 Jan 2007

照顧Care of ✔ 嬰嬰兒

Baby兒童Children

⾧者Elderly

傷殘Disable

臥床Bedridden

寵物Pet

離職原因Reason Leaving

Finished Contract

成⼈Adult 2

兒童Child

年齡Age

嬰嬰兒Baby 1(G)

⾧者Elderly

傷殘Disabled

臥床Bedridden

依 次 序 做 得 最 好 家 務Proficiency Rank (No.1 BEST to No.14)

3 烹飪飪Cooking 4 洗烫烫⾐服

Washing & Ironing 5 清清潔Cleaning 2 照顧嬰嬰兒

Baby care 1 照顧兒童Child care

學童輔導Children tutoring 6 照顧⾧者

Elderly care 7 照顧傷殘Disabled care 8 照顧臥床

Bedridden care 9 照顧寵物Pet Care

藥理Pharmacology

駕駛駛Driving 10 洗⾞

Car washing 11 園藝打理Gardening

有經驗Experience

願意學習Willing

To Learn

⼯作能⼒及經驗Work Ability & Experience

(1) 照顧初⽣⾄三個⽉⼤嬰嬰兒Take care of newborn to 3 months baby. Employer ✔( ) ( )

(2) 照顧三⾄⼗⼆個⽉⼤嬰嬰兒。Take care of 3 to 12 months baby. Myself ✔( ) ( )

(3) 照顧⼀⾄五歲⼩孩。Take care of children 1 to 5 years old. Employer ✔( ) ( )

(4) 照顧五歲以上孩童。Take care of children over 5 years old. Employer ✔( ) ( )

(5) 輔導學童⼯課。Tutoring Children. No Experience ( ) ✔( )

(6) 照顧⾧者。Take care of elderly. No Experience ( ) ✔( )

(7) 照顧臥床。Take care of bedridden. No Experience ( ) ✔( )

(8) 照顧傷殘。Take care of disabled. No Experience ( ) ✔( )

(9) ⼀般家務。General household chores. Employer ✔( ) ✔( )

(10) 照料寵物。Take care of pets Others ✔( ) ✔( )

(11) 護理寵物偏好Preference for Pets Care Afraid of dog but can take care other pets ( ) ✔( )

(12) 中菜烹飪飪Chinese Food Cooking Steam Fish, soup, chicken ✔( ) ( )

(13) 西餐烹飪飪Western Food Cooking ( ) ✔( )

(14) 使⽤家庭電器Using Home Appliances Yes ✔( ) ( )

(15) ⼿洗⾐服Hand Washing Laundry Yes ✔( ) ( )

(16) 簡單縫紉紉Simple Sewing Yes ✔( ) ( )

(17) 洗⾞Car Washing No ( ) ✔( )

(18) 園務Garden Keeping No ( ) ✔( )

Page 2

Maid No.JFA163H

家庭狀況Family Status

配偶年齡Age of Spouse 46

配偶職業Spouse's Occupation Farmer

兒⼦年齡Son's Age 8 / 19

⼥兒年齡Daughter's Age

兄弟年齡Brother's Age 36 / 46 / 49

姊姊妹年齡Sister's Age 33 / 40

家中排⾏Rank in the family 3

⽗親年齡Father's Age

母親年齡Mother's Age

個⼈嗜好Personal Hobby

⼀般資料

General Information是Yes(✔) 否

No(✘)

(1) 申請⼈曾經申請來港⼯作Applicant has ever applied to work in Hong Kong applied in Hong Kong ✔( )

(2) 申請⼈之前曾經在港⼯作Applicants has ever worked in Hong Kong before worked in Hong Kong ✔( )

(3) 申請⼈對某些⾷物/藥物過敏Applicant is allergic to some food/medicine ✘( )

(4) 申請⼈在過去5年中曾接受過⼿術Applicant has had surgery in the past 5 years ✘( )

(5) 申請⼈有⽪膚問題Applicant has a skin problem ✔( )疾病disease part of forehead bald since born

(6) 申請⼈的部分肢體有別於常⼈Part of the applicant's body is different from ordinary ✘( )

(7) 懂懂駕駛駛Applicant can drive ✘( )

(8) 申請⼈吸煙Applicant smoking ✘( )

(9) 申請⼈接受每週休息⽇安排在平⽇Applicant accept weekly rest day on weekdays ✔( )

(10) 申請⼈接受在有需要時額外⼯作Applicant accept extra duties when necessary ✔( )

(11) 申請⼈保持⽇常個⼈衛⽣Applicant maintain daily personal hygiene ✔( )

(12) 申請⼈偏⾷Applicant is a picky eater ✘( )

(13) 申請⼈可接觸豬豬⾁Applicant can touch pork ✔( )

(14) 申請⼈可進⾷豬豬⾁Applicant can eat pork ✘( )

以上資料由申請⼈提供及確認以上資料正確無訛，若資料不符必須由申請⼈承擔責任All information given above were provided & confirmed by applicant. Applicant is liable for all responsibilities for any false information found.

Page 3

Maid No.JFA163H

以 往 受 僱僱 為為 傭 ⼯ 紀 錄Previous Employment as a Domestic Helper

(3) 僱僱主姓名Name of Employer Lam Wai Sheung

僱僱主國籍Nationality Chinese

⼯作地點Country Hong Kong

主要⼯作Job Description ✔ 烹飪飪

Cooking ✔ 家務Housekeeping

醫務護理Nursing

⼯作期間Preiod

由From 12 Feb 2007

⾄To 13 Apr 2008

照顧Care of

嬰嬰兒Baby

兒童Children

⾧者Elderly

傷殘Disable

臥床Bedridden

寵物Pet

離職原因Reason Leaving

ER moved to othercountry

成⼈Adult 4

兒童Child

年齡Age

嬰嬰兒Baby

⾧者Elderly

傷殘Disabled

臥床Bedridden

Page 4