Employee INFORMATION

(KINDLY FILL ALL DETAILS IN CAPITAL LETTERS)

STAFF ID…………………………………………………………………...
TITLE: MR MRS MISS DR CHIEF PROF (Pls Tick where appropriate)
GENDER: MALE FEMALE

SURNAME………………………………………………………………………………………………………………………………………………….
FIRST NAME……………………………………………………………………………………………………………………………………………….
SECOND NAME……………………………………………………………………………………………………………………………………………….

OFFICIAL DATA

PRE-EMPLOYMENT MEDICAL SCREENING DATE…………………………………………...

HEALTH STATUS: FIT TEMPORARY FIT
ENTRY DATE………………………………………………………………………...
ENTRY GRADE/STEP…………………………………………………………….
ENTRY DESIGNATION…………………………………………………………...
ENTRY SALARY (ANNUAL)………………………………………..............
COMPANY……………………………………………………………………………. PASSPORT
DEPARTMENT……………………………………………………………………….
BRANCH………………………………………………………………………………..

PERSONAL DATA

BIRTH DATE (DD/MM/YY) …………………………………………… STATUS: MARRIED SINGLE WIDOW WIDOWER

HOMETOWN……………………………………………. ETHNICITY/TRIBE ………………...………………………………
LGA…………………………………………...……. STATE OF ORIGIN…………………………………. NATIONALITY…………………….………….

PERMANENT HOME ADDRESS……………………………………………………………………………………………………………………………………

CURRENT ADDRESS……………………………………………………………………………………………………………………………………………………
1.PERSONAL PHONE NO ………………………………...………. 2. PERSONAL PHONE NO …………………………….……………………….
PERSONAL EMAIL………………………………………………………………………………………………………………………………….………………….
PERSONAL DATA CONT.

NAME OF SPOUSE……………………………………………………………………………………………………………………………………………………..……
SPOUSE ADDRESS……………………………………………………………………………………………………………………………………………………………
SPOUSE PHONE NO. 1 …………………………….……………….……….… SPOUSE PHONE NO. 2…………………………………………………….
NO OF CHILDREN…………………………………………………………………………………………………………….....................
CHILD 1…………………………………………………………………….……………D.O. B (DD/MM/YYYY)……………………………… AGE………………
CHILD 2…………………………………………………………………….…………...D.O. B (DD/MM/YYYY)…………………………….. AGE………………
CHILD 3…………………………………………………………………………………..D.O. B (DD/MM/YYYY)……………………………. AGE………………
CHILD 4……………………………………………………………………………………D.O. B (DD/MM/YYYY)………………………….... AGE……………..

NEXT OF KIN NAME…………………………………………………………………………RELATIONSHIP……………………………………………………….

ADDRESS………………………………………………………………………………………NEXT OF KIN PHONE NO…………………………………………

BENEFICIARY……………………………………………………………………………RELATIONSHIP………………………………………………………….
ADDRESS……………………………………………………………………………………… BENEFICIARY ………………………………………………………

EDUCATIONAL DATA

SCHOOLS NAME LOCATION DEGREE, COURSE OF DURATION

(CITY/STATE) STUDY AND CLASS OF e.g START DATE
e.g WARRI/DELTA (DD/MM/YY) –
DEGREE
STATE END DATE (DD/MM/YY)
e.g BSC. BUSINESS ADMIN, Second
class upper (2:1)
PRIMARY START DATE:
SCHOOL
END DATE:

SECONDARY START DATE:

SCHOOL
END DATE:

HIGHER START DATE:

INSTITUTION
END DATE:

OTHERS START DATE:

END DATE:
NYSC DATA

NYSC CALL UP NO. NYSC STATE CODE STATE OF SERVICE DURATION

e.g DELTA STATE e.g START DATE (DD/MM/YY) –
END DATE (DD/MM/YY)
START DATE:

END DATE:

NYSC EXEMPTION DATA (If applicable)

REASON FOR EXEMPTION ……………………………………………………………………………………………………………………………………….
DATE ISSUED (DD/MM/YY) ………………………………………………………………………………………………………………………………………

PROFESSIONAL QUALIFICATIONS DATA

NAME OF CERTIFICATE START DATE LOCATION MEMBERSHIP

PROFESSIONAL BODY RECEIVED (DD/MM/YY) - e.g WARRI/DELTA STATUS
STATE ACTIVE OR INACTIVE
END DATE (DD/MM/YY)
1. START DATE:

END DATE:

2. START DATE:

END DATE:

PROFESSIONAL LICENSE DETAILS

NAME OF REGISTRATION NO. EXPIRATION LOCATION MEMBERSHIP STATUS

PROFESSIONAL BODY DATE e.g WARRI/DELTA STATE ACTIVE OR INACTIVE

1.

2.
PREVIOUS WORK EXPERIENCE
(Relevant/Cognate experience to the role for which you have been employed)

NAME OF COMPANY POSITION COMPANY ADDRESS DURATION REASON FOR

(JOB ROLE) e.g START DATE (DD/MM/YY) – LEAVING
END DATE (DD/MM/YY)

1. START DATE:

END DATE:

2. START DATE:

END DATE:

3. START DATE:

END DATE:

INPUT CONVERSION

ENTRY GROSS PAY ……………………………………………………………………………………………………………………………………………………

BANK ACCOUNT NUMBER…………………………………………………………PAY BANK………………………………………………………………

ACCOUNT TYPE: CURRENT A/C SAVING A/C

NATIONAL IDENTIFICATION NUMBER (NIN)………………………………………………………………………………………………………………

TAX IDENTIFICATION NUMBER………………………………………………………………………………………………………………………………….

PENSION

ADMINISTRATOR………………………………………………………………………………………………………………………………………..

PENSION NUMBER…………………………………………………………………………………………………………………….................................

LAST EMPLOYER DETAILS

(The last place of work you resigned from before joining Lily Hospitals )

PREVIOUS EMPLOYER………………………………………………………………………………………………………………………………………….

ADDRESS OF PREVIOUS EMPLOYER ………………………………………………………………………………………………………………………

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

OFFICE EMAIL………………………………………………………………………..OFFICE PHONE………………………………………………………

Signature…………………………………………………………Date………………………………………………………………
REFERENCES
(You are to ensure that your referee details are correct as you cannot be confirmed until feedback has been received from them)

NAME RELATIONSHIP COMPANY PHONE NO. EMAIL

1.

2.

Acknowledgment and Authorization

I, ________________________________________________, certify that all information

provided is true and complete to the best of my knowledge. I give full consent to verify the
information and to be contacted if any information provided is found to be false, incorrect, or
misleading, whether given in my application, interview, or this form, I understand that my
employment may be subject to termination or other disciplinary actions.

Signature: ………………………………………………….……….. Date: ……..……………………………………..