UTHM/PP/UPS-04 (BI) /2013

APPLICATION FOR APPOINTMENT ON CONTRACT BASIS

FOR ACADEMIC POST

Photograph
Passport Size
(Compulsory)

NAME : ……………………………………………………………………………………………

RESIDENTIAL STATUS:

PERMANENT RESIDENT

(NON CITIZENS)
Country Origin: …………………………….
State Origin : ……………………………..

POSITION APPLIED : …………………………………………………………………………..

FACULTY : ………………………………………………………………………………………..

(PLEASE FILL THE FORM USING BLOCK LETTERS)

 A. PERSONAL DETAIL

Full Name : ……………………………………………………………………………………………........

Mailing Address : …………………………………………………………………………………………..

………………………………………………………………………………………………………………..

Permanent Address : ……………………………………………………………………………………..

………………………………………………………………………………………………………………..

Tel. office : ……………………………… Tel. home: …………………………………………………...

Fax. No. : ………………………………….. Mobile No : …………………………………

E-mail Address : ………………………………

Identity Documents No/Passport No : …………………………………………………………

Sex : ………………………………………………..

Date of Birth: ……………………………. Place of Birth : ………………………………........

Passport Expiry Date : …………………. Marital Status :………………………………………..

SPOUSE INFORMATION
Spouse’s Name : …………………………………………………………………………………..

Occupation : ………………………………………………………………………………….…….

Address: …………………………………………………………………………………….........

……………………………………………………………………………………………………….

Tel. office : ………………………………………………………………………………………….

Nationality: ………………………………………………………………………………………….

Passport No : ……………………………………………………………………………………...
 B. LANGUAGE PROFICIENCY

Please tick  in the appropriate boxes provided

Language Spoken Written

Excellent Excellent
1. English
Good Good

Poor Poor

Excellent Excellent
2.Others ……………………….
Good Good

Poor Poor

Excellent Excellent
3. Others ……………………….
Good Good

Poor Poor

4. TOEFL / IELTS Score : …………………………………

Date : ………………………………….

C. ACADEMIC QUALIFICATIONS

University/College/School Date/Year Certificate/Diploma/ CGPA/Grade/ Date

Degree Class Awarded
 D. ACADEMICS DETAILS

Degree Awarded Specialization/ Major Title of Dissertation/Thesis (if any)

Please indicate areas of specialization :

Research interest :

E. FIELD SPECIALIZATION
Status
Employer Duration Salary
Position Full/Part Time/
Please specify (USD)
Contract
 F. REFEREES
(Please name two persons not related to you whom you have contacted)

And agreed to be your referees

1. Name : …………………………………………………………………………………………………..

Address: ………………………………………………………………………………………..............

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Designation: …………………………………………………………………………………………….

Tel. No: ………………………………………………………………………………………...............

E-mail: …………………………………………………………………………………………………..

2. Name : …………………………………………………………………………………………………..

Address: ………………………………………………………………………………………..............

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Designation: …………………………………………………………………………………………….

Tel. No: ………………………………………………………………………………………...............

E-mail: …………………………………………………………………………………………………..
 G. FAMILY DETAILS (DEPENDANTS ONLY)

Please provide details of person that will be accompanying you if you are appointed
Name Age Sex Date of Birth Relation Birth Cert. No

……………………… ……. ……. …………………….. ………….. ………………..

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H. DECLARATION

I hereby declare that:

The information given in this application from is true and correct. University Tun Hussein
Onn Malaysia has the right to terminate my service if the information given is found to be
false

Signature : …………………………………….

Date : …………………………….
Name : ……………………………………….