Asean Centre For Biodiversity: Personal History Form
Asean Centre For Biodiversity: Personal History Form
Asean Centre For Biodiversity: Personal History Form
1. Name
Family Name First Name Middle Name Maiden Name, if any
11. This assignment may require travel and engagement in physical activities.
Are there any limitations on your ability to perform in the prospective field of work? YES NO
12. Have you taken up legal permanent residence status in any country other than that of your nationality?
13. Have you ever been arrested, indicted, or summoned into court as a defendant in a criminal proceeding, or convicted, fined or imprisoned
for violation of any law (excluding minor traffic violations)?
14. Have you been disciplined in, or dismissed from, any of your previous assignments?
15. Address:
Residence:
Office:
Communication:
17. Dependants
If you have any dependants, list them below.
18. Education
List all university degree, professional or other equivalent qualifications obtained
Name, Place and Country Years Attended Degree and Academic Main Course of Study
Distinction Obtained
From To
Month/Year Month/Year
List schools or other formal training or education from age 14 (e.g. high school, technical school or apprenticeship)
Years Attended
Name, Place and Country Type Certificates or Diploma Obtained
From To
Month/Year Month/Year
19. Employment
Starting with your present post, list in reverse order every employment you have had. Also include service in the armed forces and note any
period during which you were not gainfully employed. If you need more space, please use the attached additional pages
Fax Number:
Email:
3
Reason for leaving:
Fax Number:
Email:
Fax Number:
Email:
4
Job Title Type of Business From (Month/Year) To (Month/Year)
Fax Number:
Email:
20. Have you any objections to our making inquiries from your present or previous employer? YES NO
23. Languages
5
Easily Easily Easily Easily
24. Referees
List three persons, not related to you, who are familiar with your character and qualifications. Do not repeat the names of supervisors listed
under Employment
I certify that the statements made by me in answer to the foregoing questions are true, complete, and correct to the best of my knowledge and
belief. I understand that any misrepresentation or material omission made on this Personal History Form or other document requested by the
ASEAN Centre for Biodiversity (ACB) renders a staff member of the ACB liable to termination or dismissal.
Date: Signature:
Note: You may be requested to supply copies of documentary evidence to support the statements you have made above. Do not, in any event,
submit the original text of reference or testimonials unless they have been obtained for the sole use of this application.