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)

MRG/application form
1
 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

MRG/application form
2
 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: _________________________

_______________________ ________________________
_______________________ ________________________
_______________________ ________________________
_______________________ ________________________

MRG/application form
3
 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

MRG/application form
4