PRIVATE & CONFIDENTIAL

IMU EDUCATION SDN BHD

Photo

INTERNATIONAL MEDICAL UNIVERSITY
No. 126, Jalan Jalil Perkasa 19, Bukit Jalil
57000 Kuala Lumpur, Malaysia.
Tel: +603-86567228 Fax: +603-86568836
Website: www.imu.edu.my
(For Academic Appointments )
STAFF APPOINTMENT APPLICATION FORM
Please complete the application form in BLOCK LETTERS and enclose a passport
size photograph. No spaces should be left blank. If it is not applicable write N/A or
NIL. Copies of Certificates or testimonials should be attached. The originals should
be brought to the interview.

Post applied for : PROFESSOR IN PATHOLOGY (HISTOPATHOLOGY)

PERSONAL PARTICULARS
Name in full
MAXIMO B. AXIBAL, JR.
Postal Address
1- C SULATAN ST. , MANDALUYONG CITY
Tel No. (Home) :
533Tel No. (Office) :
6733
Mobile No.:

E-Mail

:

0917- axibalmdpath@yahoo.com.ph

8400- 261
Date & place of birth: AUGUST 1, 1958

Age: 54

Sex : MALE

Single
/
Married
Divorced
Marital
Status :
Please ()
tick
Country of Domicile : PHILIPPINES
Citizenship : FILIPINO
I/C No. (Color) or Passport No.
EB3193245
Language
Proficiency:

Date & Place issued:
28 JUL 11/ DFA MANILA
TAGALOG; Religion:
ROMAN

ENGLISH

CATHOLIC

Hobbies/Interests:

READING
BOOKS
F:Staff/Application Form/StaffApplicationFormFaculty/2010

International Medical University

1

18 Father’s Name : MAXIMO R. PICA. of Children : SIX Children’s Ages : 26. 20.AXIBAL (DECEASED) Profession: TEACHER Employer: N/A Brothers: Sisters: ROMEL HAZEL FERDINAND NELIA ELMER EDUCATION (State School/College/University attended with dates): F:Staff/Application Form/StaffApplicationFormFaculty/2010 International Medical University 2 .PRIVATE & CONFIDENTIAL FAMILY DETAILS Spouse’s Name: MARIA GERTRUDES C. SR. 22. (DECEASED) Profession: LAWYER Employer: N/A Mother’s Name : CRISTINA B. 24.AXIBAL Profession: INDUSTRIAL PHYSICIAN Employer: ANGELUS MEDICAL CLINIC No. BOSQUE. AXIBAL. 19.

ENGLISH LIST AREAS OF RESEARCH INTEREST: PROFESSIONAL QUALIFICATIONS (with dates and other relevant information): SCHOLARSHIPS & OTHER ACADEMIC AWARDS (dates and awarding body): MEMBERSHIPS (names of Association/Society. and date joined): F:Staff/Application Form/StaffApplicationFormFaculty/2010 International Medical University 3 . etc.PRIVATE & CONFIDENTIAL DIPLOMA/DEGREES (state areas of concentration/specialization) Diploma/Degree/University Month & Year Awarded Specialization TITLE OF MASTERS/DOCTORATE DISSERTATION (PLEASE ATTACH ABSTRACT): INDICATE SPECIFIC AREAS OF TEACHING: LANGUAGES FLUENT IN: TAGALOG.

PRIVATE & CONFIDENTIAL WORKING EXPERIENCE* Post Held Employer Name of Post Name and Full Address Dates From Until * For each post held. please describe. briefly job specifications and responsibilities Present Salary RM Expected Salary RM PUBLICATIONS & PRESENTATIONS (please append): PUBLIC/COMMUNITY SERVICES: F:Staff/Application Form/StaffApplicationFormFaculty/2010 International Medical University 4 Period of Notice required .

PRIVATE & CONFIDENTIAL REFEREES (Please give title. address. e-mail and telephone numbers of 3 referees who can comment on your academic and working experience) 1. briefly describe how you can contribute effectively to the IMU. relationship) _______________________________________ Have you applied to IMU before? YES (If yes. ADDITIONAL INFORMATION Do you know anyone in International Medical University (IMU)? YES / NO / NO / NO (If yes. state name. 3. Based on the information you have received from us and your own background experiences. 2. state position & year/month of application)________________________ Have you ever been charged and/or convicted in any criminal court of law? F:Staff/Application Form/StaffApplicationFormFaculty/2010 International Medical University 5 YES . full name.

YES including family business? (If yes. after engagement. the particulars given in this form are found to be false or incorrect. I understand that any misrepresentation of facts given herein will be sufficient cause for IMU to summarily terminate my appointment if.PRIVATE & CONFIDENTIAL (If yes. please give details) ____________________________________________ MEDICAL AND PHYSICAL STATUS Have you suffered from or are you currently suffering from / YES serious illness? (If yes. please provide details) YES / NO / NO ______________________________________ Have you any active interest in any business undertaking. please provide exact details): STATUS POST ACUTE MYOCARDIAL INFACTION WITH FIVE STENT ANGIOPLASTY (YEAR 2008) Are you suffering from any physical disabilities? YES / NO NO (If yes. Enclosed are copies of my education/professional qualification certificate/diploma/degree and/or appropriate recommendation letters. please provide details) ______________________________________ Have you ever been sued and /or convicted for bankruptcy? (If yes. please provide exact details)____________________________________ I declare that the information given in this application is true and accurate and I understand that it is a condition of employment that I satisfactorily pass a medical examination. ____________________________ _______________________________________________ Date : F:Staff/Application Form/StaffApplicationFormFaculty/2010 International Medical University Signature : Name: 6 .