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To be completed by the Head of Department (where applicable) and
forwarded by him (with applicant's Confidential Report) direct to the
Chief Medical Director, University of llorin Teaching Hospital, P.M.B
1459, Ilorin, Kwara State, Nigeria.
Can the applicant be released from his present employment without
penalty? If not please give details: 19. Are you under any bond, if so state condition/nature of
bond
20. Date onwhich you can assume duly if
successful ANY Ds
21. Three References (Two of whom should have professional knowledge of
candidate in His/her area of speciality where applicable or under whom he/she has
worked.
Name Rank Address
DOCTORMOMOHIBRAHIM CHIEF MEDICAL DIRECTOR (cMD) ‘OKENGWE GENERAL HOSPITAL
22. Have you any objection to your present employer being
contacted?
23. Have you ever been convicted by a law
Court? ...
24, Attach any other information which would assist in assessing your
suitability?
25. CERTIFICATION
a. I certify that on my honour the above information is to the best of my
knowledge and belief the truth | also understand that if the above information
is discovered to be false even after | have been employed, the Board of
Management of the University of llorin teaching Hospital reserves the right to
terminate my appointment.
Date
Signature ...- WeBrtactatst.
b. ‘CONFIDENTIAL Qualification and Grade in Subject
taken
12, University detals (any) Fes
Degree
Class of Degree
University
Date ..
Other Degree
University
Date ..
13. Professional Qualification (if any) with dates
14. Previous appointments (place, dates of commencing and leaving)
a
Employer Dales Reason for leaving
PREMIER MEDICAL CENTER Era 2022 2024 _
15. Present
Employer
16. Name of
Employer
17. Date of Appointment
Salary .......39,090.
Present
18. Present Duties and
responsibilities .. MonNine suier, Nationality
4. Normal place of
Domicile IHIMA OKEHI OKENE KOGI STATE NIGERIA
\Y BE REQUIRED)
5. Contact
‘Address... PRO/IHAQ/22 INATA WARD II, OBEIBA IHIMA. OKEH) LGA KOGI STATE
6. Telephone 09034854120. E
mail iat Oar one
7. Famly details (Where applicable)
(a) Spouse Name
©)
(b) Personal Children
Name Date of Birth Place of residence
8. Next of Kin and
9. Telephone
mail.
10. Permanent Address (if different from 5 above)
11. Schools attended (with dates) including Professional Training UNIVERSITY OF ILORIN TEACHING HOSPITAL
P.M.B 1459, z
ILORIN, KWARA STATE.
Please complete this Form in Duplicate: attach separate sheet for
Additional Information.
1. Post applied
for...
Department/Unit.....9
2. PERSONAL DETAILS:
(a) Surname (in
Capitals) ..... Dahan
Other
Names...
(b) Married or Single.
..(¢) Sumame before
marriage........ SINGLE
(d) Date of Birth .....22NOVEMBER1993._(e) Male or
Female ..
() Place of
Birth |HIMA OKEHI LOCAL GOVERNMENT OKENEKOGI STATE
STAT
(g) State of Origin ..
IMA LGA... OKEHILGA
...TownWillage
(h) Language
‘Spoken .....FNGLSH.GRIRA/HALISAIYORURA.....
(i) Passport No. () Date and place ofissue of
Passport ..
Ak) Validity of
Passport
