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HOMELAND SECURE AFRICOM

(Applicants Are Advised To Read The Attached Instructions Carefully Before Completing This Form)

PA R T A : P E R S O N A L I N F O R M AT I O N

By filling and endorsing this form, you have accepted
that you will pay a non-refundable volunteer membership
registration fee of (N3,500.00) Three Thousand Five
Hundred Naira only.

SURNAME (block Letters)

OTHER NAME(S)

D AT E O F B I R T H

AGE

GENDER
Male

S TAT E O F O R I G I N

HEIGHT

WEIGHT

Female

LOCAL GOVERNMENT AREA

N AT I O N A L I T Y

S TAT E O F R E S I D E N T

PERMANENT ADDRESS

TELEPHONE NUMBER

MAILING ADDRESS

E-MAIL ADDRESS

NEXT OF KIN
SURNAME (block Letters)

OTHER NAME

ADDRESS

R E L AT I O N S H I P

PA R T B : A C A D E M I C Q U A L I F I C AT I O N ( S )
NAME OF
INSTITUTION(S)

1
2
3
4

(Attach photocopy of relevant certificate(s) only)

PERIOD
( F r o m - To )

Q U A L I F I C AT I O N ( S )
O B TA I N E D

PA R T C :

EMPLOYMENT RECORDS

SURNAME (Employer)

OTHER NAME(S)

ADDRESS

N AT U R E O F J O B

D AT E O F A P P O I N T M E N T

ANY BOND WITH YOUR PRESENT EMPLOYER
Ye s

If”YES” FOR HOW LONG

No

H AV E Y O U A N Y O B J E C T I O N S T O O U R M A K I N G E N Q U I R E S A B O U T Y O U F R O M Y O U R P R E S E N T E M P L O Y M E N T
Ye s

No

PA R T D : M E D I C A L I N F O R M AT I O N
H AV E Y O U S U F F E R E D F R O M A N Y P H Y S I C A L A N D M E N TA L D I S A B I L I T Y
Ye s

No

D O Y O U H AV E A N Y A L L E R G I E S
Ye s

I F “ Y E S ” S TAT E N AT U R E O F D I S A B I L I T Y

I F “ Y E S ” P L E A S E S TAT E T H E N AT U R E O F A L L E R G Y

No

H AV E Y O U O R Y O U R PA R E N T S O R C L O S E R E L AT I O N S E V E R S U F F E R E D F R O M M E N TA L I L L N E S S , A L C O H O L I S M O R
DRUG ADDICTION:
I F “ Y E S ” S TAT E
Ye s

No

BLOOD GROUPS

PA R T E : C R I M I N A L D I S C I P L I N A R Y R E C O R D S
H AV E Y O U E V E R B E E N C O N V I C T E D , F I N E D O R I M P R I S O N E D B Y A C O U R T O F L A W F O R A N Y V I O L AT I O N ( E X C L U D I N G M I N O R
TRAFFIC OFFENCES?)
I F “ Y E S ” G I V E F U L L PA R T I C U L A R S O F T H E O F F E N C E C O M M I T T E D A N D P E N A LT Y A W A R D E D
Ye s

No

PA R T F : N A M E S A N D A D D R E S S E S O F G U A R A N T O R S
SURNAME (Guarantor)

OTHER NAME(S)

ADDRESS

A

SURNAME (Guarantor)

OTHER NAME(S)

ADDRESS

B

PA R T G : A P P L I C A N T ’ S O AT H O F A L L E G I A N C E
I. I,
hereby solemnly affirm that I understand that HSA is
commissioned to operate in a mediating security peace keeping capacity where there are crises or where its
services is needed in Nigeria. Therefore I will not constitute crises or any act of criminalities to HSA by exhibiting
haughty or hot tempered spirit throughout my service with Homeland Secure Africom in Nigeria (HSA)
ii. That I shall co-operate with the Homeland Secure Africom Administration in all respect,
iii. That I shall disassociate my self from committing any act of criminality dissidence, subversive activities, unlawful
act(s) including private or public , protest in the State and Nation at large.
iv. That I shall obey and accept any form of disciplinary measure that results from breaching this Oath of Allegiance
and Code of Conduct and rebellious act against HSA constituted authority.

PA R T H : C A N D I D AT E ’ S D E C L A R AT I O N
I,

H E R E B Y D E C L A R E T H AT T H E I N F O R M AT I O N G I V E N I N T H I S

A P P L I C AT I O N I S T H E T R U T H A N D N O T H I N G B U T T H E T R U T H .

RIGHT THUMB PRINT
S I G N AT U R E O F C A N D I D AT E
D AT E

FOR OFFICIAL USE ONLY
APPROVED

COMMENTS BY SCREENING COMMITTEE

DISAPPROVED

ENCLOSURES:
B I R T H C E R T I F I C AT E
Ye s

E D U C AT I O N A L

No

1

4

2

5

____________________
L . G . A . S TAT E O F O R I G I N
Ye s

No

SIGNATURE/DATE

ANY OTHER
3

T h e C i v i l i a n F a c e o f T h e Wa r o n Te r r Ø r

n Office: 1 Akure Street, Area 10 FCT n Website: www.homelandsecureafricom.com n Tel: 07084884666