POSITION(S) APPLIED FOR : ______

DATE OF APPLICATION : ______

Friend Recommend Friend Scheme

Job Referred By: ______Department: ______
(name of staff)

Instructions: Please fill in all fields. Those marked (*) are optional. Delete where applicable for those marked (#)

(A) PERSONAL PARTICULARS
Name as in NRIC / Passport (underline surname) :
Address: / Postal Code:
Tel: (H) / Mobile: / Email:
NRIC / FIN / Passport No.:
/ Nationality:
/ Citizenship#:
Singapore Citizen / SPR / Others :
Currently on any pass: (For non-Singapore Citizens / Residents only)
Employment Pass / S Pass / Work Permit / Others:
*Date of Birth: / #Gender: F / M / *Marital Status: / *Religion:
(B) FAMILY PARTICULARS (NEXT-OF-KIN, SPOUSE AND/OR CHILDREN)
Name / Relationship / Age / Occupation / Employer
(C) EMERGENCY CONTACT
Name: / Relationship:
Local Address:
Tel: (H) / Tel: (O) / Mobile:
(D) ACADEMIC PARTICULARS
School / College / Polytechnic / University / From / To / Highest Standard
(State month & year)
(E) PROFESSIONAL MEMBERSHIP
Registration / Enrolment No. of Singapore Nursing Board:
(SRN, SCM, SEN)
Registration No. of Singapore Medical Council / Pharmacy Board / RPI# etc.:
Others, please specify: / Type: Full / Conditional / Temporary#
(F) EMPLOYMENT DETAILS - Present Employment
Name & Address of Employer:
Description of Duties:
Position When Employed: / Current Position:
From
(Month/Year) / To
(Month/Year) / Basic Salary: (S$) / AWS (month/s): / Other Bonus (month/s):
Gross Salary: (S$) / Reason/s for leaving present job:
Annual Leave: / Type of Allowances:
Resignation Notice Period required: / Earliest Commencement Date: / Expected Basic Salary:
EMPLOYMENT DETAILS - Previous Employment (Please state in chronological order starting with most recent)
From
(Month/Year) / To
(Month/Year) / Name of Employer / Job Title / Last drawn Basic Pay / Reason/s for Leaving
(G) OTHER INFORMATION
National service status : not applicable exempted full time part time : from ______to ______
Vocation: / Unit Attached: / Rank: / Next-In-Camp:
Languages / Dialects
Written & Spoken: / Languages / Dialects
Spoken Only:
Hobbies:
(H) CHARACTER REFERENCES
(Please provide the name and contact information of two persons to whom reference about your past moral character, conduct, academic and professional achievements can be made.)
Name / Occupation / Years Known / Address / Email / Telephone nos.

Please answer the following questions: ** (If yes, please give details)

(1) / Have you suffered any form of infectious / contagious disease? ** / Yes / No
(2) / Have you any physical disability? ** / Yes / No
(3) / Have you ever been fined / convicted of a criminal offence in any court of law? ** / Yes / No
(4) / Have you been dismissed or suspended from service of any employer? ** / Yes / No
(5) / Do you have any current and/or past medical conditions? ** / Yes / No
(6) / Have you previously applied for employment in this company? ** / Yes / No
(7) / Do you have any relatives / friends working in this company? ** / Yes / No
(I) APPLICANT’S CONSENT & DECLARATION
(1) / I consent for any inquiries on my personal data, employment history & performance, financial status or medical history and other related matters as may be necessary for the purpose of making an employment decision in connection with my employment application. I hereby release employers, schools or persons from any liability in responding to these inquiries.
(2) / I declare that the information given in this application is true and accurate and understand that any misrepresentation of facts called for herein will be sufficient case for dismissal from the Hospital’s employment.
(3) / Attached herewith are copies of relevant supportive documents for this application.
Applicant’s Signature / Date

AUTHORISATION AND RELEASE OF DOCUMENTS & INFORMATION

TO MOUNT ALVERNIA HOSPITAL

I. ______, ______(full name of applicant) (NRIC/Passport)

hereby authorise every person, hospitals, accreditation agencies, professional societies, institutions of tertiary education, professional associations, licensing authorities and their appropriate sources in authority in which I have been trained or practiced to release records, documents and information concerning my licensure, professional qualifications and competency, character and other information pertaining to me to the representatives of the Human Resource Department, Mount Alvernia Hospital.

I further request and authorise that the requested information, document and records be sent directly to

Human Resource Department Mount Alvernia Hospital 820 Thomson Road Singapore 574623

I hereby release and discharge the Human Resource Department Mount Alvernia Hospital, its agents and all persons, hospitals, accreditation agencies, professional societies, institutions of tertiary education, professional associations, licensing authorities and their appropriate sources in authority having control from any and all liability for any communications, reports, records, statements, documents, recommendations or disclosures involving me made in good faith and without malice requested or received by the Human Resource Department Mount Alvernia Hospital.

I agree and understand that the authorisation given by me shall be irrevocable for a period of one year and that a copy of this authorisation shall be as binding as the original.

Signed by In the presence of

______Full name of Applicant Full name of Witness

______Signature Signature

______Date Date

App Form-06/2014