Lecturer Application Form

For Official Use Only LPU

JWTN

DATA

Please affix a recent photograph

UNIVERSITI SAINS MALAYSIA

here

APPLICATION FORM CONTRACT STAFF Please complete the form in BLOCK LETTERS and kindly submit 7 copies.

1. POSITION APPLIED FOR Position

Post is Professor

Dental Officer

Assoc Professor

Full time

(contract)

Part time

(visiting)

Medical Officer Department

Sr. Lecturer Advertisement seen in

Lecturer Language Instructor

2. PERSONAL DETAILS Full Name as in Passport / Identity Card (underline Surname / Family Name):

Title (Prof / Dr / Mr / Mrs / Ms, etc)

Mailing Address:

Postcode: Home Tel No.

Office Tel No.

Fax No.

E-mail

Date of Birth

Gender:

Religion

Male

Nationality

Female

Passport No.

3. FAMILY BACKGROUND Full Name

Date & Place of Birth

Nationality

Occupation

Present Address

Spouse Child(ren)

4. QUALIFICATION Degree

Name & Address of Awarding Institution

Major Field of Study

Dates Attended /Date Graduated

Name & Address of Awarding Institution

Date

First Degree

Higher Degree(s)

Professional Qualification(s)/ Registration(s)

Type/Class

Use this space to provide additional information you wish to include/ you may use additional sheet if necessary:

5. CURRENT EMPLOYMENT Name & Address of Current Employer:

Current Appointment

Current Gross Annual Salary

Date of Appointment

6. PROFESSIONAL EXPERIENCE (Most recent first, use additional sheet if necessary) From

To

Name & Full Address of Employer

Post Held

7. ADDITIONAL INFORMATION IN SUPPORT OF APPLICATION (Use additional sheet if necessary) Courses/Subjects Taught

Research Interests

Research Supervision

Awards, Research Grants and Contracts

Publications (Should only include publications in recognised academic journals/books, please provide full publication details, e.g. all authors, titles, dates)

Conference Presentations (Please provide full details)

Any Other Relevant Information

8.

REFEREES (Please provide 3 referees. Send the attached “Referee Report Form” to your referees and request them to forward the form to USM)

Name and Address

Tel No.

Fax

E-mail

Fax

E-mail

Fax

E-mail

Name and Address

Tel No. Name and Address

Tel No.

9. DECLARATION I declare that all the information on this application is true and correct to the best of my knowledge. I understand this information is subject to verification, and my employment and/or continuance thereof may depend upon its accurateness.

Signature of Applicant

Date