UNDERGROUND MINING ALLIANCE

Obuasi Office
AGA Obuasi Site

APPLICATION FOR EMPLOYMENT

Position Date
Desired ................................................................................................................. Available ....................................

Alternative Position Salary

Desired ................................................................................................................. Expected ....................................

PERSONAL DATA

Surname ............................................................... First Name.....................................................................................

Nationality................ ............................................. Hometown .....................................................................................

Permanent Address .............................................. Date of Birth.........................................Age: ..................................

Telephone No’s ..................................................... (home) .......................................................................... (business)

Spouse’s Name
Marital Status ........................................................ Name.............................................................................................

No. of Children Under 18 yrs................................. Dates of Birth ................................................................................

of children
.............................................................................. ......................................................................................................

.............................................................................. ......................................................................................................

Beneficiary: ........................................................... ......................................................................................................

Do you have a Social Security Card? Yes/No If so, give #....................……………...........................

Do you have a Labour Card? Yes/No If so, give .................................................................

Do you have a Drivers Licence? ........................... Licence No. ..................................... Place of Issue.......................

Class (es) .............................................................. Expiry Date........./....../........

Do you have first aid qualifications? Yes/No If so, what..............................................

May we contact your present employer? .............. ......................................................................................................

GENERAL

How did you learn of our Company? ..................... ......................................................................................................

Are you prepared to work shift work as required?.

Are you prepared to work overtime as required? ..

Medical History

1. Please give brief details and dates of any serious illness, operations and disabilities:
(You will be required to attend a pre-employment medical examination and drug screen.)

.............................................................................. ......................................................................................................
.............................................................................. ......................................................................................................

2. Do you wear prescription glasses or contact lenses? ..................................................................................

3. Have you ever claimed worker’s compensation or common law damages for any injury or ........ disease?

NO YES (If YES, give full details)

.............................................................. ......................................................................................................

4. Do you suffer from any illness or disease or disability not mentioned above?

NO YES (If YES, give full details) .................................................

5. Do you regularly take any prescription medication or illegal drugs? ............................................................

Character References (either personal or business)

1. .............................................................. ......................................................................................................

2. .............................................................. ......................................................................................................

Have you ever been convicted of a serious offence?

NO YES (If YES, give full details)

.............................................................. ......................................................................................................
EDUCATION Certificates,
Location Dates Enrolled Grade/Courses Diplomas
From To
School

Trade, Technical/
Technological

University

Other qualifications or
certificates for example
welding, Safety,
Management, supervision
Courses.

Languages spoken

Languages written

WORK HISTORY List work experience, starting with present employer

1. Company Name:_________________________________________________________________

2. List job duties, equipment/machinery operated__________________________________________

______________________________________________________________________________

3. Start Date_______________________________________

4. Termination Date_________________________________

5. Job Tilte________________________________________________________________________

6. Reason for Leaving_______________________________________________________________

1. Company Name:_________________________________________________________________

2. List job duties, equipment/machinery operated__________________________________________

______________________________________________________________________________

3. Start Date_______________________________________

4. Termination Date_________________________________

5. Job Tilte________________________________________________________________________

6. Reason for Leaving_______________________________________________________________

1. Company Name: _________________________________________________________________

2. List job duties, equipment/machinery operated__________________________________________

______________________________________________________________________________

3. Start Date_______________________________________

4. Termination Date_________________________________

5. Job Tilte________________________________________________________________________

6. Reason for Leaving_______________________________________________________________

Validation of Citizenship. Select any of the below that qualifies your Citizenship.

Choose the option by circling the number

1. Hails from the Community

2. One or both parents from the community
3. Lives in the community and/or has immovable property in the community
4. Married to someone from the community
5. Born in the Community
6. A trustworthy individual as affirmed/endorsed by the community leaders
 PHOTO

It is agreed that previous employers may be contacted unless specifically noted to the contrary on this form. I
understand that false declarations or omissions in answers to the foregoing questions render the applicant liable to
dismissal and or negation of Worker’s Compensation entitlement.

I have read (or have had read to me) and understand the above questions and do solemnly declare that the
information shown above is true and complete. I clearly understand that in the event of my application being
successful, my employment is subject to the relevant contract and terminable by either party giving the requisite
notice.

Signed ................................................................... Date..............................................................................................

Community Name: ……………………………………………….

Confirmed by:

Designation Name Signature Date

Traditional
Leader(Odikro)

Assembly
Member

Unit Committee
Chairman

Divisional Head