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Application Form: Hukm/Jsm/Upp/Br01

This document is an application form for a position at the Hospital Universiti Kebangsaan Malaysia. It requests personal details such as name, address, citizenship, education history. It also asks for employment history, references, and a declaration confirming the truth of the information provided. Applicants are to attach certified copies of documents including passports, degrees, and recommendation letters.

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31 views4 pages

Application Form: Hukm/Jsm/Upp/Br01

This document is an application form for a position at the Hospital Universiti Kebangsaan Malaysia. It requests personal details such as name, address, citizenship, education history. It also asks for employment history, references, and a declaration confirming the truth of the information provided. Applicants are to attach certified copies of documents including passports, degrees, and recommendation letters.

Uploaded by

dzlfqr
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
Download as pdf or txt
Download as pdf or txt
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HUKM/JSM/UPP/BR01

HOSPITAL UNIVERSITI KEBANGSAAN MALAYSIA


Jalan Yaacob Latif, Bandar Tun Razak
56000 Cheras, Kuala Lumpur Photograph
MALAYSIA
Tel: 603-91733333 Ext: 2117/2009
Fax: 603-91737149

APPLICATION FORM
Please fill this form in capital letters

1. Position Applied : __________________________________________________________


Area of Expertise : __________________________________________________________
(if any)

A. PERSONAL PARTICULARS
2. Full Name : __________________________________________________________
(as stated in passport)
Other Name/Names : __________________________________________________________
(If any, including maiden name)

3. (a) Postal Address: (b) Permanent Address:


_________________________ _________________________
_________________________ _________________________
_________________________ _________________________
_________________________ _________________________
4. Date of Birth : ______________________ 5. Place of Birth : __________________
6. Age : ______________________ 7. Sex : __________________
8. Citizenship : ______________________ 9. Race : __________________
10. Religion : ______________________
11. (a) Identity Card No.: ___________________ (b) Place of Issue : __________________
(if any)
12. (a) Passport No. : ______________________ (b) Date of Issue : __________________
(c) Place of Issue: ______________________ (d) Date of Expiry : __________________
13. Email : ______________________________________________________________
14. Telephone No. : ______________________ 15. Fax No. : __________________

16. (a) Marital Status : ______________________ (b) Name of Spouse: _________________

(c) Citizenship : ______________________


(Spouse)

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HUKM/JSM/UPP/BR01

(d) Dependants:
(Spouse and children below 18 years of age, single and not in employment.)

Name and Address


Passport No. /
No. Name Age Occupation of Employer or
I/C No.
School/College

B. QUALIFICATIONS

17. Education and training

Degree,
Diploma and Date of
Year Achievement/
Name of University/ College Certificate award
Qualifications
(Starting from the most Obtained or Any
(e.g : 1st class
recent) Professional
honours) Month/Year
From Until Examination
Passed

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HUKM/JSM/UPP/BR01

C. CURRENT OCCUPATION:

18. (a) Position: __________________________________________________________

(b) Employer: __________________________________________________________________

(c) Employer's Address: __________________________________________________________

(d) Basic Salary (Per Month): ____________________ (e) Allowances: ____________________


(Please attach letter of confirmation from employer)

D. PREVIOUS EMPLOYMENT

19. (Letter of confirmation from employer would be useful. Please use attachments if space is
insufficient)

Duration
Positions Name and Address of Employer
From Until

E. REFEREES

20. (a) (i) Name: __________________________ (b) (i) Name: ___________________________

(ii) Occupation: ______________________ (ii) Occupation: _______________________

(iii) Address: ________________________ (iii) Address: _________________________


_______________________ ________________________
_______________________ ________________________
_______________________ ________________________
_______________________ ________________________

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HUKM/JSM/UPP/BR01

F. DECLARATION

21. I hereby declare that the information given and any documents attached are nothing but the truth.
If the information is found to be incorrect, the application will be null and void. If I have been
appointed, I will accept immediate termination.

_________________________ Date: ___________________________


(Signature)

Please attach the following documents along with the application form:

1. Certified Copies of Passports [including spouse and dependants (all pages)]


2. Certified Copies of Degrees/Diplomas or Certificates
3. Copies of Recommendation Letters (if any)

Address to:

MANAGER
HUMAN RESOURCE DEPARTMENT
TINGKAT 1, KOMPLEKS PENDIDIKAN PERUBATAN
CANSELOR TUANKU JA'AFAR, HOSPITAL UNIVERSITI KEBANGSAAN MALAYSIA
JALAN YAAKOB LATIF, BANDAR TUN RAZAK
56000 CHERAS, KUALA LUMPUR
MALAYSIA

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