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PERSONAL PARTICULARS
Full Name (as per NRIC/Passport) :
Preferred Name :
Correspondence Address :
.................................................................................................................
.................................................................................................................
................................................................
Tel No. (Home) :
Mobile No.:
Date & Place of birth:
Marital Status (please ()
E-Mail :
Age:
Gender :
Married
Single
Divorced
tick):
Country of Domicile :
Citizenship :
Place issued :
Religion
(non-compulsory
section):
Hobbies/Interests
:
StaffApplicationForm_Faculty/2013
FAMILY
DETAILS
Spouses Name:
Profession :
Employer:
No. of Children :
Childrens Ages :
EDUCATION
(Please complete all column. Information declared here will be concurrently
binding with the CV submitted for this application.)
Certificate/Diplo
ma/
Degree/Professi
School/College/
University/Associ
ation
StaffApplicationForm_Faculty/2013
Specialization
onal
METHODOLOGIES
YOU
ARE
StaffApplicationForm_Faculty/2013
WORK EXPERIENCE
(For each post held, please describe briefly on job specifications &
responsibilities. Information declared here will be concurrently binding with
the CV submitted for this application.)
Present Salary/per
month
(RM)
Employer
Name and Full Address
Expected Salary/per
month
(RM)
Dates
From
Until
Period of Notice
required
APPLICANTS SELFASSESSMENT
Assessment area
Yes / No
ii.
Participation in curriculum
development
Yes / No
iii.
Innovations in curriculum
development and delivery as
evidenced by awards (eg education
awards, innovation grants, etc.)
Yes / No
StaffApplicationForm_Faculty/2013
iv.
Yes / No
i.
Yes / No
ii.
H-index of applicant*
Yes / No
iii.
iv.
v.
Yes / No
Yes / No
Yes / No
cont
Assessment area
i.
Yes / No
ii.
Yes / No
iii.
Yes / No
StaffApplicationForm_Faculty/2013
iv.
Yes / No
i.
Yes / No
ii.
Yes / No
iii.
Yes / No
Based on the information you have received from us and your own experience,
briefly describe how you can contribute effectively to the IMU in not less than 500
words.
StaffApplicationForm_Faculty/2013
ADDITIONAL INFORMATION
How did you get to know about this position in International Medical University
(IMU)?
IMU Website
Newspaper
Journals
Friends/Relatives
Others (please state) _________________________________________
Do you know anyone in International Medical University (IMU)?
YES
NO
YES
NO
YES
NO
______________________________________
NO
______________________________________
Have you ever been sued and /or convicted for bankruptcy?
(If yes, please provide details)
YES
NO
NO
NO
YES
____________________________
_______________________________________________
Date
StaffApplicationForm_Faculty/2013
qualification
Signature
Name: