APPLICATION FOR EMPLOYMENT

POSITION APPLIED FOR:
DATE:

NAME IN FULL: (Block letters & under surname)
ALIAS: (If any)
MAIDEN NAME: (In the case of married woman)
HOME ADDRESS:
EMAIL ADDRESS 1:
EMAIL ADDRESS 2:
TELEPHONE NO:
DATE/PLACE OF BIRTH: AGE:
PASSPORT NO./
IC NO		 SEX:
DATE/PLACE OF ISSUE: MARITAL STATUS:
INCOME TAX NO: RACE/DIALECT:
EPF NO: RELIGION:
SOCSO NO: CITIZENSHIP:
PASSPORT NO:
(Non-Sarawakian Only)		 EXPIRY DATE:
HEIGHT:
(In CM)		 WEIGHT:
(In KG)

PARTICULARS OF OTHER MEMBERS OF THE FAMILY:
NAME RELATIONSHIP AGE OCCUPATION

NEXT OF KIN TO BE CONTACTED IN CASE OF EMERGENCY

NAME: RELATIONSHIP:
ADDRESS:
TELEPHONE:
(Home)
(Office)
QUALIFICATIONS

1) ACADEMIC

NAME OF SCHOOL

 FROM TO CERTIFICATE AWARDED INCLUDING DETAILS
OF SUBJECTS TAKEN AND GRADE OBTAINED
NAME OF COLLEGE / UNIVERSITY FROM TO DEGREE / DIPLOMA AWARDED
2) PROFESSIONAL

NAME OF INSTITUTION

FROM

TO

CERTIFICATE / DIPLOMA /
MEMBERSHIP AWARDED
3) REGISTRATION/ENROLMENT WITH THE RELEVANT NURSING BOARD
    (For Nursing Staff)
SRN REG NO: DATE REGISTRATION / ENROLLED:
MIDWIFERY NO: DATE REGISTRATION / ENROLLED:
STATE ENROLLED NURSE NO: DATE REGISTRATION / ENROLLED:
4) OTHERS

COURSES ATTENDED

FROM

TO

CERTIFICATE AWARDED
PRESENT EMPLOYMENT
Name and address of company/firm:
Nature of duties/Field of Nursing:
From: To: Position held: Salary draw:
PREVIOUS EMPLOYMENT
Name and address of company/firm:
Nature of duties/Field of Nursing:
From: To: Position held: Salary draw:
Name and address of company/firm:
Nature of duties/Field of Nursing:
From: To: Position held: Salary draw:
Name and address of company/firm:
Nature of duties/Field of Nursing:
From: To: Position held: Salary draw:
OUTSIDE ACTIVITIES
(eg. Participation in sports/games, membership of clubs, associations, hobbies, etc.)

OTHER RELEVANT INFORMATION IN SUPPORT OF YOUR APPLICATION
(Details of scholarships, awards or other distinction obtained, offices held in school, college, university or professional and other organizations should be given)

REFERENCES
(N.B. Referees must not be related to the applicant in any way but should preferably be your present employer)
1) Name:
  Address:
  Occupation:
2) Name:
  Address:
  Occupation:
   

YES

NO
1) Are you an undischarged bankrupt?
If so, please give details:
     
2) Have you ever been convicted of any criminal offence?
If so, please give details:
     
3) Have you ever suffered from any serious illness?
If so, please give details:
     
4) Do you suffer from any physical handicap?
If so, please give details:
     
5) Are you pregnant at time of application?
If yes, please indicate months of pregnancy
     
6) Do you have a valid driving license?
If yes, driving license no:
     
7) Has your driving license ever been suspended, revoked or put on probation?
If so, please give details:
     
8) Have you ever had any traffic accident and/or traffic violations over the Past 3 years?
If yes, how many times?
     
LANGUAGE AND LEVEL OF PROFICIENCY
Spoken:
Written:
Expected Salary:  
If selected, when can you assume duty:
I declare that the above particulars are correct and true, I am aware that any false information given will lead me to an instant dismissal should my application be considered.
  N.B. Photocopies of all relevant documents including passport size photo, certificates and testimonials etc. should be submitted by post and are not returnable to Normah Medical Specialist Centre, P.O. Box 3298, 93764 Kuching.

Original should not be enclosed but should be presented for inspection at the interview.

 

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