Ministry of Health APPLICATION FORM May, 2013 Please provide the information below in CLEAR and CAPITAL Letters. Please note: the Ministry reserves the right to post applications to wherever a vacancy exists and wherever the Ministry deems appropriate. - First Name: “Surname: “NRC N: Sex: J Primary Cor*act Number (personal mobile): Date of Birth: Nationality: : Marital Status: {you are married, please attach a certified copy of the marriage certficate(marital status Is nota basis for placement. Position: (Example: Registered Nurse, Enrolled Nurse, Clinical Officer ~ Psychology, etc}: Tertiary Institution Attended: Date Gradv- ted (Month/Year) District Preference: Please choose your preferred FOUR (ONE URBAND AND THREE RURAL) districts and Indicate the “District Number" below, in order of preference. ‘Atthough Moll will consider preferences when making deployment assignments, MoH will not guarantee that preferences will be met, First Choice: . Third Choice: (provide the district number) {provide the district number) Second Choice: Fourth Choice: (provide the di.irct number) (provide the district number) ‘ate