CONFIDENTIAL
*
FAMILY INFORMATION [Parents, brothers, sisters, spouse, children]
Note: DOB for children is mandatory to facilitate benefits claim
In the event of emergency, please contact :
SOCIAL ACTIVITIES
Major Social, Leisure and Sporting Activities especially Achievements and Positions of
Responsibility
ACADEMIC AND PROFESSIONAL QUALIFICATIONS OBTAINED [Please provide supporting documents]
COURSES CURRENTLY PURSUING
LANGUAGES/ DIALECTS [State level of proficiency - Fluent/ Fair/ Slight]
EMPLOYMENT HISTORY [Please start with current employment & give details of employment
including vacation work and industrial training. Use attachments where necessary]
DECLARATION
1. Are you suffering from any illness and/or medical condition, mental disorder or
physical impairment?
2. Are you bound by any bond to serve the government, or any organization?
3. Have you been charged or convicted in a court of law in any country, or an offence
involving fraud or dishonest act or violence or in respect of banking, securities and
insurance laws?
4. Have you been charged with any offence in a court of law in Malaysia or any other
country for which the outcome is not yet known?
5. Have you engaged in any business practices appearing to be deceitful or oppressive or
which otherwise reflect discredit on your method of conducting business?
6. Have you been dismissed or suspended from the service of any employer?
7. Are you presently/have you ever been under investigation for fraud or other dishonest
act or misconduct whatsoever by your current or past employer?
8. Are you a bankrupt or a discharged bankrupt, whether within or outside of Malaysia?
9. Do you have any secured and/or unsecured debts?
10. Are you being or have you been sued – in any Court of Law?
11. Are you in default of payment of any debt?
12. Are you or have you been a director, manager, agent or guarantor of any company,
including one which has been wound up?
13. Do you have any other sources of income besides your salary?
14. Have you applied to us previously?
If yes to any of the above, please give details here.
15. # May we contact your previous employer[s]?
16. # May we contact your present employer[s]?
# CHARACTER REFEREES [Present, past & immediate superiors]
Qualitfication
ANY ADDITIONAL INFORMATION
[Which you may wish to add]: