Form A2 KOFORIDUA POLYTECHNIC

APPLICATION FORM FOR

SENIOR STAFF / MEMBERS

1. JOB PARTICULARS:

a. Post Applying For:………………………………………………………………………………………

b. Part-Time or Full-Time:………………………………………………………………………………

2. PERSONAL PARTICULARS:

a. Surname (Block Letters):………………………………………………………………………………..

b. First Name:………………………………………………………………………………………………

c. Middle Name(s):………………………………………………………………………………………...

d. Date of Birth:…………/…………../…………… Place of Birth……………………………………

e. Religion:………………………………………… Denomination:…………………………………...

3. CONTACT ADDRESS:

a. Present Contact Address:……………………………………………………………………………….

…………………………………………………………………………………………………………..

b. Telephone No. (s):……………………………… Fax (if any):…………………………………….

4. PARENTAGE & NATIONALITY:

a. Name of Father:………………………………… Alive or Dead:………………………………….

b. Address (if alive):……………………………………………………………………………………….

c. Name of Mother:………………………………... Alive or Dead:………………………………….

d. Address (if alive):……………………………………………………………………………………….

e. Nationality and How Acquired:…………………………………………………………………………

f. If naturalized citizen, give number and date of certificate and name in which it was granted:

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1.
5. MARITAL STATUS:
a. Married or Single:……………………………………………………………………………………….

b. If Married, Name and Address of Spouse:………………………………………………………………

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c. Number of Children:…………………………………………………………………………………….

d. Names and ages of Children:……………………………………………………………………………

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e. Any Other Dependent(s) and age(s):…………………………………………………………………….

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6. ACADEMIC QUALIFICATION(S):

a. The Highest Qualification:…………………………………………… Date:………………………..

b. Professional Qualification/Membership (if any) and Date(s) acquired:

i. …………………………………………………………………………………………………...
ii. …………………………………………………………………………………………………...

iii. …………………………………………………………………………………………………...

7. EDUCATION:

a. Basic Schools attended and dates (from & to):

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2.

b. Secondary/Other Non-Tertiary Schools attended and dates:

 Schools From To Certificates Awarded Subjects Studied

c. Universities & Polytechnics – Degree, HND & Post Graduate Courses Studied

Institution(s) From To Certificate(s) Programmes

Awarded Studied

d. A brief detail of any Research/Publication/Invention/design or Contribution to knowledge and

date (if any):……………………………………………………………………………………………...

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3.

e. For Teaching Staff Only: What special areas of interest do you prefer to teach if appointed?
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8. CURRENT EMPLOYMENT (if any):

a. Position/Rank:……………………………………………………………………………………………

b. Company/Institution/Department:……………………………………………………………………….

c. Address of Employers:…………………………………………………………………………………..

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d. Salary (per annum):…………………………………… e. SSF No:………………………………...

9. PREVIOUS EMPLOYMENT(S) (if any):

Names and Addresses of Position(s) Held From To Reason(s) for

Employers Leaving

(You may use another sheet if necessary)

4.

Have you ever been dismissed? If yes, when?:………………………………………………………….

Reason(s):………………………………………………………………………………………………..
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10. REFERENCE:

1 2 3
Name Status Postal Address

a. ……………………………… …………………………. ……………………………….

b. ……………………………… …………………………. ………………………………..

c. ……………………………… ………………………….. ………………………………..

(Referees should not be relatives and friends)

d. Do you mind if enquiries should be made from any of your previous or present employers?
Yes or No: (underline) If Yes, which of them do you advise against?
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11. EMERGENCY: In case of any emergency who should we contact?

a. Name:…………………………………………………… b. Tel No:…………………………………..

c. Address:…………………………………………………………………………………………………..

d. Town:……………………………………………………. e. Street:…………………………………...

f. House No:………………………………………………………………………………………………..

12. UNDERTAKING: I confirm that the above information are true and undertake that any false
Information detected should cause my employment (if made) to be nullified.

a. Signature:…………………………………………………. b. Date:…………………………………...

c. Full Name (Surname Last): (……………………………………………………………………………)

FOR OFFICE USE ONLY:

a. Date interviewed:…………………………………………... b. Appointed? Yes/No

c. Date of Assumption of Duty:……………………………………………………………………………...

5.