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Application for Appointment You may take approximately 30 minutes to fill up this form. The following documents will be required for completing the form:

  

Identity Card/Passport Educational Certificates National Service Certificate of Service (if applicable)

POST APPLIED FOR:

Date & source of advertisement:

Will you consider other posts beside the post applied for? Yes / No

PERSONAL DETAILS Title and Full Name as in Passport / Identity Card (underline Surname / Family Name):

Name in Chinese characters, if applicable:

Dr / Mr / Mrs / Mdm / Miss Home Address:

Contact Nos.:

Postal Address (if different from Home Address):

(Office)

(Mobile)

(Home)

(Fax)

E-mail Address: Nationality: Singapore Permanent Resident:

Foreign Address (if applicable):

Yes

No

If yes, please attach a copy of Entry Permit and indicate:Date PR issued: For Singapore / Malaysian Citizens and Singapore PRs only Identity Card No.:

Date of Birth:

Country of Birth:

Colour:

Pink

Old Identity Card No.:

Blue

(For Malaysian Citizens Only)

Ethnic Group:

Religion:

Gender: Male / Female

Marital Status: Single / Married / Divorced / Widowed / Separated

For Foreigners only Passport No.:

Date of Issue:

Place of Issue:

Date of Expiry:

Personalized Employment Pass (PEP) holder (Attach copies of PEP endorsement & card): PEP No.: Date of Issue:

Date of Expiry:

EDUCATION (List Schools / Institutions / Universities attended and currently attending. Please attach copies of relevant certificates and transcripts) From

To

Schools / Institutions / Universities

Duke-NUS Graduate Medical School Singapore 8 College Road Singapore 169857 A school of the National University of Singapore (RCB No: 200604346E)

Country

Qualifications Attained

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EMPLOYMENT DETAILS (Starting with your present appointment. Use separate sheet if necessary) Name of Employer

Employment Period

Monthly Base Salary

Allowances

Reason(s) for Leaving

From To

Position Held Key Portfolios

Key Achievements

Please state current / latest bonuses-

Expected Gross Salary:

13th Month AWS

Resignation Notice Period:

Variable Bonus

Name of Employer

Yes / No _____ month(s)

May we write to your previous employer(s) for a reference?

Earliest Commencement Date if Appointed:

Employment Period

Yes / No

Monthly Base Salary

Allowances

Reason(s) for Leaving

Monthly Base Salary

Allowances

Reason(s) for Leaving

Monthly Base Salary

Allowances

Reason(s) for Leaving

From Position Held

To

Key Portfolios

Key Achievements

Name of Employer

Employment Period From

Position Held

To

Key Portfolios

Key Achievements

Name of Employer

Employment Period From

Position Held

To

Key Portfolios

Key Achievements

Duke-NUS Graduate Medical School Singapore 8 College Road Singapore 169857 A school of the National University of Singapore (RCB No: 200604346E)

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REFEREE (Provide name and contact number of 3 referees who know you in your previous employment, where two of them must be your supervisors) Name Contact Number

Contact/ Email Address Occupation

Company Relationship

NATIONAL SERVICE RECORD (Please attach a copy of the NS Certificate of Service) Date Enlisted

Date Discharged

Type of Service SAF / SPF / SCDF

Highest Rank Attained

If you have not served National Service, state whether you have been exempted. Yes / No / Not applicable If so, please quote Exemption Notice number and date:

FAMILY BACKGROUND Full Name

Date & Place of Birth

Nationality

Occupation

Father Mother Spouse

Children (if applicable)

Is your spouse or any of your relative(s) presently working in the University?

Yes / No

If Yes, please state his/her name, relationship and department ____________________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS 1.

Have you ever been convicted in a court of law in any other country?

Yes / No

2.

Have you been charged with any offence in a court of law in Singapore or in any other country for which the outcome is pending?

Yes / No

3.

Are you aware of being under any current police investigations in Singapore or in any other country following allegations made against you?

Yes / No

4.

Have you ever been dismissed, discharged, terminated or suspended from employment?

Yes / No

5.

Have you been, or are you under any financial embarrassment?

Yes / No

6.

Have you ever had, or are you suffering from any

7.

-

medical condition?

Yes / No

-

physical impairment?

Yes / No

-

mental illness?

Yes / No

Have you ever had any surgical operation previously?

Yes / No

If your answer is “Yes� to any of the questions above, please state details below (use separate sheet if necessary). ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Duke-NUS Graduate Medical School Singapore 8 College Road Singapore 169857 A school of the National University of Singapore (RCB No: 200604346E)

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PLEASE ANSWER THE FOLLOWING QUESTIONS (CONTINUED) 8.

Have you received any award that requires you to serve a bond?

Yes / No

If Yes, please specify bond period and organization that you are/were bonded to. If you have not successfully completed the bond, please provide details in a separate sheet of paper. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

9.

Please list down any awards/publications/research projects that you have obtained/ completed. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

HOBBIES / INTERESTS (Please give a write-up of no less than 300 words on your hobbies/interests)

DECLARATION

I declare that the particulars in this application are true to the best of my knowledge and belief, and I have not wilfully suppressed any material facts. Any misrepresentation or omission of information will be grounds for withdrawal of an employment offer or for dismissal.

Signature of Applicant

Date

Last updated on 25.04.08

Duke-NUS Graduate Medical School Singapore 8 College Road Singapore 169857 A school of the National University of Singapore (RCB No: 200604346E)

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