Professional Documents
Culture Documents
(Applicants Are Advised To Read The Attached Instructions Carefully Before Completing This Form)
PA R T A : P E R S O N A L I N F O R M AT I O N
OTHER NAME(S)
D AT E O F B I R T H
AGE
GENDER
Male
S TAT E O F O R I G I N
HEIGHT
WEIGHT
Female
N AT I O N A L I T Y
S TAT E O F R E S I D E N T
PERMANENT ADDRESS
TELEPHONE NUMBER
MAILING ADDRESS
E-MAIL ADDRESS
NEXT OF KIN
SURNAME (block Letters)
OTHER NAME
ADDRESS
R E L AT I O N S H I P
PA R T B : A C A D E M I C Q U A L I F I C AT I O N ( S )
NAME OF
INSTITUTION(S)
1
2
3
4
PERIOD
( F r o m - To )
Q U A L I F I C AT I O N ( S )
O B TA I N E D
PA R T C :
EMPLOYMENT RECORDS
SURNAME (Employer)
OTHER NAME(S)
ADDRESS
N AT U R E O F J O B
D AT E O F A P P O I N T M E N T
No
H AV E Y O U A N Y O B J E C T I O N S T O O U R M A K I N G E N Q U I R E S A B O U T Y O U F R O M Y O U R P R E S E N T E M P L O Y M E N T
Ye s
No
PA R T D : M E D I C A L I N F O R M AT I O N
H AV E Y O U S U F F E R E D F R O M A N Y P H Y S I C A L A N D M E N TA L D I S A B I L I T Y
Ye s
No
D O Y O U H AV E A N Y A L L E R G I E S
Ye s
I F Y E S S TAT E N AT U R E O F D I S A B I L I T Y
I F Y E S P L E A S E S TAT E T H E N AT U R E O F A L L E R G Y
No
H AV E Y O U O R Y O U R PA R E N T S O R C L O S E R E L AT I O N S E V E R S U F F E R E D F R O M M E N TA L I L L N E S S , A L C O H O L I S M O R
DRUG ADDICTION:
I F Y E S S TAT E
Ye s
No
BLOOD GROUPS
PA R T E : C R I M I N A L D I S C I P L I N A R Y R E C O R D S
H AV E Y O U E V E R B E E N C O N V I C T E D , F I N E D O R I M P R I S O N E D B Y A C O U R T O F L A W F O R A N Y V I O L AT I O N ( E X C L U D I N G M I N O R
TRAFFIC OFFENCES?)
I F Y E S G I V E F U L L PA R T I C U L A R S O F T H E O F F E N C E C O M M I T T E D A N D P E N A LT Y A W A R D E D
Ye s
No
PA R T F : N A M E S A N D A D D R E S S E S O F G U A R A N T O R S
SURNAME (Guarantor)
OTHER NAME(S)
ADDRESS
SURNAME (Guarantor)
OTHER NAME(S)
ADDRESS
PA R T G : A P P L I C A N T S O AT H O F A L L E G I A N C E
I. I,
hereby solemnly affirm that I understand that HSA is
commissioned to operate in a mediating security peace keeping capacity where there are crises or where its
services is needed in Nigeria. Therefore I will not constitute crises or any act of criminalities to HSA by exhibiting
haughty or hot tempered spirit throughout my service with Homeland Secure Africom in Nigeria (HSA)
ii. That I shall co-operate with the Homeland Secure Africom Administration in all respect,
iii. That I shall disassociate my self from committing any act of criminality dissidence, subversive activities, unlawful
act(s) including private or public , protest in the State and Nation at large.
iv. That I shall obey and accept any form of disciplinary measure that results from breaching this Oath of Allegiance
and Code of Conduct and rebellious act against HSA constituted authority.
PA R T H : C A N D I D AT E S D E C L A R AT I O N
I,
H E R E B Y D E C L A R E T H AT T H E I N F O R M AT I O N G I V E N I N T H I S
A P P L I C AT I O N I S T H E T R U T H A N D N O T H I N G B U T T H E T R U T H .
DISAPPROVED
ENCLOSURES:
B I R T H C E R T I F I C AT E
Ye s
E D U C AT I O N A L
No
____________________
L . G . A . S TAT E O F O R I G I N
Ye s
No
SIGNATURE/DATE
ANY OTHER
3
T h e C i v i l i a n F a c e o f T h e Wa r o n Te r r r