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Ubth Application Form Original

This document contains an application form for employment at the University of Benin Teaching Hospital in Nigeria. The form requests personal information such as name, date of birth, address, education history, professional qualifications, references, and availability date. It instructs applicants to submit the original form plus 13 photocopies, along with copies of relevant certificates, to the hospital's Human Resources department.

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Taiwo Chris Awoyemi
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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2K views3 pages

Ubth Application Form Original

This document contains an application form for employment at the University of Benin Teaching Hospital in Nigeria. The form requests personal information such as name, date of birth, address, education history, professional qualifications, references, and availability date. It instructs applicants to submit the original form plus 13 photocopies, along with copies of relevant certificates, to the hospital's Human Resources department.

Uploaded by

Taiwo Chris Awoyemi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIVERSITY OF BENIN TEACHING HOSPITAL, NIGERIA.

APPLICATION FORM

PLEASE ENSURE TO WRITE IN BLOCK LETTERS ONLY

Application for the post: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1. Name in full: Surname: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _


Other Names: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Maiden Name (optional): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _
2. Date of Birth: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Gender: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Place of Birth: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3. State of Origin: _ _ _ _ _ _ _ _ _ _ _ _ _ _ LGA of Origin: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Nationality: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Marital Status: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4. Number of Children with Ages: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5. Postal Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
GSM Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ e-Mail: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
6. Residential Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
7. Permanent Home Town Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
______________________________________________________
8. Next of Kin: (1) Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _
Relationship: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _

(2) Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Relationship: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _

9. INSTITUTIONS
Pease state name of Schools/ Colleges attended: -

School Date Entered Date Exited Qualification obtained with date

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10. DETAILS OF PROFESSIONAL QUALIFICATION/ TRAINING
Please state name of Hospital, Colleges or Institutions attended: -

Qualification(s) Certificate No. Date Name and Address of Training


Obtained School/ Institution

11. If you were sponsored for a course, state whether you have been released from bond by your
sponsor (YES/ NO).
12. Present Appointment: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Salary: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Name of Employer: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
13. Nature of present duties and responsibilities: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
14. Reason(s) for wishing to leave present employment: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
15. Previous Appointment (with dates of commencement and exiting).

Employing Authority Post Held From To Reason for leaving

16. Have you been convicted of any criminal offence? (YES/ NO).
17. Have you been previously dismissed from the Public Service? (YES/ NO).
Has your appointment been previously terminated? (YES/ NO).
If YES, please state in details: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

NOTE: - Detection of concealment of facts or falsehood in this regard shall be


enough grounds for Non-employment or subsequent termination of
appointment without notices.

2|Page
18. REFERENCES: - Give the names and address of three (3) referees; one of these must be the
Head of your Department of the College or Dean of the University you last attended. Another
must have been in professional relationship with you and can testify to your capabilities from
the post sought.

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Position: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Position: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Position: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

19. Date upon which you can assume duty if the application is successful: _ _ _ _ _ _ _ _ _ _ _ _ _ _

20. Other remarks in support of your application: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


______________________________________________________

_____________ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _
Date Signature of Applicant

INSTRUCTION ON HOW TO COMPLETE THIS APPLICATION FORM

1. Applicants should attach a photocopy of all relevant certificates to the Original of this form.

2. Applicants should thereafter make 13 copies of the filled form (do not attach photocopies of certificates please).

3. Applicants should collate the 14 copies (made up of the original form and the ’13 photocopies’) which should be
stapled or tied at the top left side of the form and forwarded to the Human Resources Department, University of
Benin Teaching Hospital, PMB 1111, Benin City, Nigeria.
4. Nominated referees must be requested to forward their confidential reports as soon as possible to the Human
Resources Department, University of Benin Teaching Hospital, PMB 1111, Benin City, Nigeria.

5. The Management Board of the University of Benin Teaching Hospital is under no obligation to give reasons or
enter any correspondence as to the failure of any candidate to secure employment.

3|Page

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