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PERPETUAL SUCCOUR HOSPITAL

Gorordo Avenue, Cebu City

 

Residency On-Line Application Form

  

Note: 1. Please Put N/A if required information is not applicable to you.

          2. Please do not use single quote ( ' ) punctuation , use instead the back single quote ( ` ) punctuation if necessary to avoid error.

          3. If you have chosen a department from the drop down menu, please leave the SPECIFY option blank.

          4. Make sure all the data you have typed up are correct before pressing the ENTER key or clicking the SUBMIT button, as your data

              cannot be edited anymore after they have been saved.

Personal Information

Department:         OR Specify:

Complete Name: 

Height:                  '   ''     Weight: Kg.       Sex:         Status:

Spouse:                No. of Children:  

Present Add:        Tel.: Cell:

Date of Birth:       , , Place of Birth:  

Religion:               In case of Emergency notify:

Relation to Applicant: Address: Tel. No.

Any important medical or health problems? (e.g. Asthma, Allergies, Diabetes, Tuberculosis, etc.)

                          

If employed before when was the last employment?

Where:                Address:

Position:              Reason for leaving:

Where you a member of a union? What? Any police record?

Employment Record

 

     Date of Employment               Name and Address                     Position                   Reason for Leaving

1.

2.

 

Educational Attainment
 

Name / Address of School

 Year Attended Year Graduated Degree Honors Received  
College  
Med. School
Post Grad. Internship Year:      
Licenses, Certificate, Professional Membership, etc.
Are you taking advanced studies? What?   
Please state the reason for applying in this Hospital. 
 

          — If given a chance to work here are you willing to uphold the high moral, the ethical and religious principles of this

               Hospital?

          — Would you be willing to abide with the policies rules and regulations of this Hospital and participate in its religious,

               social and professional activities?

          — Are you willing to sign a contract to work here for at least one year?

 

Please give the names of three persons who can vouch character and intigrity.
  Names Address Tel. No.  
1.  
2.  
3.  

 

  I here certify that all above statements are true and correct to the best of my knowledge. If employed, I promised to give my honest and unstinted loyalty to Perpetual Succour Hospital.