passport size

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UNIVERSITY MALAYA MEDICAL CENTRE

APPLICATION FORM

NAME :

NAME OF THE POST : 1.

2.

3.

1. INSTRUCTION TO APPLICANT

1. PLEASE USE ONLY ONE APPLICATION FORM EVEN THOUGH MORE THAN ONE POST APPLIED.

2. ALL INFORMATION MUST BE WRITTEN IN CAPITAL LETTERS.

3. FOR MALAYSIAN GOVERMENT SERVANTS/STATUTORY BODIES, THE APPLICATION MUST BE MADE THROUGH
HEAD OF DEPARTMENT TOGETHER WITH CONFIDENTIAL PERFORMANCE REPORT.

4. STATE ONLY THE BEST EXAMINATION RESULT.

5. PLEASE USE ADDITIONAL PAPERS IF THE SPACES PROVIDED ARE INSUFFICIENT.

6. WRITE NOT APPLICABLE IN NON-RELATED COLUMNS.

2. CHECKLIST

PLEASE SUBMIT THE FOLLOWING ITEMS ALONG WITH THE APPLICATION FORM TO ENSURE THAT YOUR
APPLICATION IS COMPLETE AND CAN BE PROCESSED FOR ADMISSION. PLEASE TICK ( ) IN THE APPROPRIATE
BOX TO INDICATE ITEMS THAT HAVE BEEN SUBMITTED.

1. APPLICATION FORM

2. CERTIFIED COPY OF ACADEMIC / TRANSCRIPT / PROFESSIONAL QUALIFICATION

3. RECENT PASSPORT SIZE PHOTOGRAPH

4. CERTIFIED COPY OF IDENTIFICATION CARD / PASSPORT/ BIRTH CERTIFICATE /

MARRIAGE CERTIFICATE – FOR FOREIGN APPLICANT ONLY

5. REPLY CARD IS FILLED AND STAMPED

6. CURRICULUM VITAE, IF APPLICABLE

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3. REMINDER

1. APPLICANT’S FAILURE TO FILL UP THE APPROPRIATE COLUMNS WITH CLEAR AND COMPLETE INFORMATION MAY
RESULT IN APPLICATION BEING REJECTED.

2. IF YOU DO NOT RECEIVE ANY REPLY REGARDING YOUR APPLICATION WITHIN 3 MONTHS FROM THE CLOSING
DATE, PLEASE ASSUME THAT YOU HAVE NOT BEEN SUCCESSFUL.

3. FOR APPLICATION VIA INTERNET, PLEASE SUBMIT YOUR APPLICATION TOGETHER WITH A POSTAL ORDER
WORTH (RM1.00) FOR PROCESSING FEES.

A. PERSONAL PARTICULARS

NAME AS IN NRIC OR
PASSPORT :

IDENTITY CARD NO.

OLD : PASSPORT NO.

(FOR EX-PATRIATES ONLY)
NEW :

PERMANENT ADDRESS :

CORRESPONDENCE ADDRESS :

TELEPHON NO. :

HOUSE : H HANDPHONE NO.

OFFICE : EXT : FAX NO:

NATIONALITY :

MALAYSIAN PERMANENT RESIDENT OF MALAYSIA OTHERS PLEASE STATE ________________

DATE OF BIRTH : - - PLACE OF BIRTH : ____________________

DAY MONTH YEAR

AGE AT CLOSING DATE : YEAR MONTH DAY SEX : MALE FEMALE

RACE : ____________________ RELIGION : _________________

MARITAL STATUS : MARRIED SINGLE WIDOW / WIDOWER DIVORCED

IF YOU ARE MARRIED, PLEASE STATE

NAME OF SPOUSE : _____________________________________ TEL. NO. : ________________

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 B. HEALTH INFORMATION

HEIGHT: ___________ CM WEIGHT: _______________KG

DO YOU HAVE ANY PHYSICAL DISABILITY? IF YES, PLEASE CLARIFY AND ATTACH RELEVANT DOCUMENT IF AVAILABLE

_______________________________________________________________________________________________________

HAVE YOU BEEN THROUGH ANY SURGERY? YES / NO

PLEASE INDICATE [√] IF YOU HAVE EXPERIENCED OR CURRENTLY SUFFERING FROM THE FOLLOWING ILLNESSES

HEART EPILEPSY ASTHMA TUBERCULOSIS MENTAL DISORDER

DISEASE

OTHER ILLNESS PLEASE SPECIFY : ______________________________

C. ACADEMIC QUALIFICATIONS

SECONDARY SCHOOL

SRP/PMR/LCE SPM/SPVM/MCE STPM/STAM/HCS

YEAR GRADE YEAR GRADE YEAR GRADE

INDEX NO: INDEX NO: INDEX NO :

SUBJECT GRADE SUBJECT GRADE SUBJECT GRADE

Malay Language _________ Malay Language _________ Malay Language _________

(and oral)

English Language _________ English Language _________ English Language _________

Mathematics _________ Modern Mathematics _________ Modern Mathematics _________

Science _________ Science _________ Science _________

History _________ History _________ History _________

Living Skills _________ Islamic Education _________ Islamic Education _________

Islamic Education _________ Georgraphy _________ Georgraphy _________

Geography _________ Biology _________ Biology _________

Others _________ Chemistry _________ Chemistry _________

______________________ Physics _________ Physics _________

______________________ Additional Mathematic _________ Additional Mathematic _________

Malay Literature _________ Malay Literature _________

Others _________ Others _________

____________________ ____________________

____________________ ____________________

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 ADDITIONAL QUALIFICATION

SUBJECT YEAR GRADE SUBJECT YEAR GRADE

Please use additional papers if nessesary

TERTIARY QUALIFICATION

BIL NAME OF QUALIFICATION AREA OF YEAR OF YEAR (CLASS / CGPA @

UNIVERSITY/INSTITUTION OBTAINED SPECIALTY ENROLLMENT QUALIFICATION EQUIVALENT)
OBTAINED

Please enclose certified copies of all certificates, degrees and transcripts. Otherwise, your application will be
considered incomplete and will not be processed. All documents written in language other than English / Bahasa
Malaysia, must be accompanied by certified English Translation.

D. ADDITIONAL QUALIFICATIONS/SKILLS (OTHER RELEVANT QUALIFICATION OR COURSES)

TYPING SHORTHAND DRIVING

FROM WRITTEN FROM PRINTED MALAY ENGLISH LICENCE PERIOD OF VALIDITY

TEXT TEXT LANGUAGE LANGUAGE CLASS

FROM TO

W.P.M W.P.M W.P.M W.P.M

NOTE : Please attach certified copy of relevant certificate/document(s)

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 E. COMPUTER SKILLS

BIL CLASS/COURSE ATTENDED NAME OF LEARNING CENTER PERIOD CERTIFICATE/

QUALIFICATION
FROM TO OBTAINED

NOTE : Please attach certified copy of relevant certificate/document(s)

F. LANGUAGE PROFICIENCY

LANGUAGE SPOKEN WRITTEN

EXCELLENT GOOD FAIR WEAK EXCELLENT GOOD FAIR WEAK

MALAY
LANGUAGE

ENGLISH
LANGUAGE

OTHER
LANGUAGE
(PLEASE
SPECIFY)

Please mark [ √ ] where applicable

G. WORKING EXPERIENCES (INCLUDING CURRENT POSITION)

NAME & ADDRESS OF NAME OF POSITION AREA OF MONTHLY PERIOD OF SERVICE

EMPLOYER SPECIALTY SALARY
FROM TO

1.

2.

3.

4.

5.

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 H. REFEREES

NAME TWO (2) REFEREES, OTHER THAN A FAMILY MEMBER OR RELATIVE, WHO REALLY KNOW YOU PERSONALLY AND
CAN PROVIDE INFORMATION ABOUT YOU. THEY MUST BE ABLE TO COMMENT ON YOUR ATTITUDE,
EMPLOYMENT/EXPERIENCE/ACADEMIC/PROFESSIONAL CAPABILITIES.

1. NAME : _______________________________________ 2. NAME : _______________________________________

ADDRESS : __________________________________ ADDRESS : ____________________________________

PHONE NO : _________________________________ PHONE NO : ___________________________________

POST : ______________________________________ POST : _______________________________________

I. PERSON TO CONTACT DURING EMERGENCY

NAME :

ADDRESS:

PHONE NO: HANDPHONE NO :

RELATIONSHIP:

J. RELATIONSHIP WITH UMMC STAFF

1. STATE WHETHER YOU HAVE ANY RELATIVE WORKING IN UMMC?

YES : NO :

2. YOUR RELATIONSHIP WITH HIM / HER

BY FAMILY DESCENDENT BY MARIAGE

PLEASE TICK [√ ] AT THE APPROPRIATE BOX

3. PLEASE STATE THE RELATIONSHIP. FOR EXAMPLE: HUSBAND / WIFE / SON @ DAUGHTER / IN LAW /
GRANDCHILD/ NIECE / NEPHEW/ UNCLE / AUNTY ETC

4. NAME : _________________________________________________________________________________________

5. POST : __________________________________________________________________________________________

6. DEPARTMENT :___________________________________________________________________________________

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 K. ADDITIONAL INFORMATION/ON EXPERIENCE/ACHIEVEMENT TO
SUPPORT YOUR APPLICATION

L. PERSONAL DECLARATION

I HEREBY DECLARE THAT ALL INFORMATION AND DOCUMENTS PROVIDED ARE TRUE, ACCURATE AND COMPLETE. I
ACKNOWLEDGE THAT UMMC HAVE THE RIGHT TO REJECT MY APPLICATION OR TERMINATE MY SERVICE AFTER THE
OFFER MADE IF THE INFORMATION AND DOCUMENTS PROVIDED ARE FOUND TO BE UNTRUE AND INCOMPLETE.

DATE : ______________________________ APPLICANT’S SIGNATURE : ________________________

M FOR UMMC STAFF ONLY PLEASE ENSURE THAT YOUR HEAD OF DEPARTMENT
FILL IN THIS SECTION)

DO YOU SUPPORT THIS APPLICATION? YES/NO

COMMENTS : ____________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

______________________ __________________________________________________
DATE SIGNATURE OF HEAD DEPARTMENT & OFFICIAL STAMP

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