KPJ INTERNATIONAL COLLEGE

of NURSING AND HEALTH SCIENCES (253703-V)

(A Member of KPJ Healthcare Berhad Group of Companies)

BORANG PERMOHONAN
APPLICATION FORM

Tarikh Temuduga
Date of Interview

:
: _____________________

Jawatan
Appointment

:
: _____________________

Bahagian
Department

:
: _____________________

GAMBAR
PHOTO

DIISI OLEH PEMOHON

TO BE FILLED BY APPLICANT

BUTIR-BUTIR PERIBADI
PERSONAL PARTICULAR

Nama Penuh (Huruf Besar)

Full Name (In Block)
Jantina
Sex

:
: ____________________________________________________________

: _____________________________
: _____________________________

Tarikh Lahir/Umur
Date of Birth/Age

:
: _____________________

No Kad Pengenalan : ___________________

Identity Card No
: ___________________
Tempat Lahir
Place of Birth

Keturunan :
Agama
Race
: _________________
Religion

:
: _______________

KWSP
EPF

:
: __________

:
: _____________

Perkeso
Socso

:
: ____________________

Warganegara :
Citizenship
: _________________
No Cukai Pendapatan :
Income Tax No
: ____________

Alamat Sekarang :
Present Address : ___________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Rev : 00

KPJIC/HR/APPF

Alamat Tetap
:
Permanent Address : _________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
No Telefon Rumah
House Telephone No

:
Pejabat
: ________________ Office

No.Telefon Bimbit
Handphone No

:
: ________________

Taraf Perkahwinan

: * Berkahwin / Bujang

:
: __________________

(Potong yang tidak berkenaan)

Marital Status

: * Married / Single
(Delete where applicable)

TARAF PENDIDIKAN / KELULUSAN

EDUCATION AND QUALIFICATION

Taraf Pendidikan
Education

:
: _____________________________________________________
(Phd / Master / Degree / Diploma / Certificates / STPM / HSC / SPM / MCE / SRP / LCE /etc)

Kelulusan
Qualification

:
:

_______________________________________________________

BUTIR-BUTIR PASANGAN/ANAK
PARTICULAR OF SPOUSE/CHILDREN

Nama Suami / Isteri

Name of Spouse : ___________________________

Nama & Umur Anak-Anak :

Name & Ages of Children :

Pekerjaan/Nama & Alamat Majikan

Occupation/Employer's Name & Address
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________

1.
2.
3.
4.
5.

Rev : 00

______________________________________
______________________________________
______________________________________
______________________________________
______________________________________

KPJIC/HR/APPF

BUTIR-BUTIR WARIS TERDEKAT

PARTICULARS OF NEXT OF KIN

Nama/Name : _____________________ Pertalian/Relationship

: __________________________

Keturunan/Race : __________________ Alamat/Address

: __________________________

Pekerjaan/Occupation : __________________

PENGALAMAN BEKERJA
WORKING EXPERIENCES

(Sila gunakan helaian lain jika ada penambahan / Please use other paper for any additional )

Syarikat
Company

Jawatan
Position

Tempoh
Years of
Service

Gaji
Salary

Sebab Berhenti
Reason for Leaving

Adakah anda mempunyai saudara-mara berkhidmat di mana-mana syarikat dalam KPJSB. (YA/TIDAK)
Do you have any relative working within KPJSB Group of Company (YES/NO)
Jika YA, sila berikan butirnya :
If YES, please provide the details :
Nama/Name : ______________________________

Pertalian/Relationship : _____________________

Pekerjaan/Occupation : _______________________

Syarikat/Company : ________________________

Bagaimana jawatan kosong diketahui :

How application came to know of vacancy : _________________________________________________

Rev : 00

KPJIC/HR/APPF

Gaji dikehendaki :
Bila boleh mula bekerja
:
Salary Expected :________________
Date when free to start
: _____________________
Butir-butir kelab, persatuan atau kesatuan sekerja :
Particular of clubs, Association Trade Unions :
______________________________________________

RUJUKAN
REFERENCES

Dua nama rujukan yang mengenali anda tetapi bukan saudara

Two references who know you well. They must NOT be relatives
1. Nama/Name : ________________________

2. Nama/Name

Alamat/Address : ______________________
_______________________________________
_______________________________________
No Tel / Tel. No :

: ____________________________

Alamat/Address

: ____________________________

No Tel / Tel. No

: __________________________

PENGESAHAN
DECLARATION

Adalah dengan ini disah bahawa :I hereby vouch that :

i) Butir-butir yang diberikan adalah benar dan betul sejauh pengetahuan saya.
Particulars given are true to my knowledge
ii) Tidak melakukan apa-apa jenayah, penyalahgunaan dadah, bankrupsi atau melakukan apa-apa
aktiviti yang bertentangan dengan undang-undang dan
Have not committed any criminal offence, drugs, bankruptcy or any other unlawful activities and
iii) Mempunyai kesihatan yang baik
I am in healthy condition
Jika ada sebahagian butir-butir yang diberikan adalah tidak benar KPJHB mempunyai hak untuk
menamatkan perkhidmatan saya dengan serta-merta tanpa menerima apa-apa faedah.
If any of the information given is found to be untrue KPJHB reserve the right to terminate my service with
immediate effect without any benefits.

Tarikh:
Date : _____________________
Rev : 00

Tandatangan
Signature

:
: _______________________
KPJIC/HR/APPF