KLINIK XOMEDIC

Bukit Jalil City Signature Shop-Offices, Attach photo here

N-8-1,
Pusat Perdagangan Bandar Bukit Jalil,
Persiaran Jalil 2,
57000 Kuala Lumpur, Malaysia.

EMPLOYMENT APPLICATION
POSITION APPLIED DATE

PERSONAL PARTICULARS
NAME BANK ACCOUNT NO.

ADDRESS NRIC NO.

PASSPORT NO.

HOME CONTACT NO. MOBILE CONTACT NO. EMAIL

MARITAL STATUS DATE OF BIRTH AGE GENDER

NATIONALITY ETHNICITY RELIGION

EPF NO. SOCSO NO. INCOME TAX NO.

FAMILY/SPOUSE
FULL NAME RELATIONSHIP AGE DOB NATIONALITY OCCUPATION

EMERGENCY NAME AND CONTACT DETAILS

FULL NAME CONTACT NO. RELATIONSHIP

Page 1
 EDUCATIONAL QUALIFICATIONS
YEAR
NAME OF SCHOOL HIGHEST QUALIFICATION ATTAINED
FROM TO

YEAR
CERTIFICATE/DIPLOMA/DEGREE HIGHEST QUALIFICATION ATTAINED
FROM TO

EMPLOYMENT HISTORY
YEAR POSITION HELD
NAME OF COMPANY COMPANY ADDRESS REASON FOR LEAVING
FROM TO LAST DRAWN SALARY

DETAILS OF DUTIES AND RESPONSIBILITIES OF PREVIOUS POSITION

APPLICANT IS INVITED TO ATTACH COPIES OF CERTIFICATES AND TESTIMONIALS RELEVANT TO THIS APPLICATION, ORIGINALS
SHOULD NOT BE SENT AT THIS STAGE.
LANGUAGE
PLEASE INDICATE LEVEL OF PROFICIENCY : 5 - VERY GOOD, 4 - GOOD, 3 - AVERAGE, 2 - POOR, 1 - VERY POOR
LANGUAGE SPOKEN READ WRITTEN

Page 2
REASONS FOR EXPLORING THIS POSITION

HOW YOU CAME TO KNOW OF THIS JOB OPENING?

REMUNERATION
PRESENT MONTHLY BASIC SALARY

EXPECTED MONTHLY BASIC SALARY

AVAILABILITY
NOTICE REQUIRED

EARLIEST DATE AVAILABLE

REFEREES
THE REFEREE MUST NOT BE A FAMILY MEMBER OR RELATED TO YOU
THE REFEREE SHOULD BE SOMEONE THAT HAS WORKED WITH YOU IN YOUR PREVIOUS EMPLOYMENT
FULL NAME COMPANY NAME & ADDRESS POSITION HELD CONTACT NO.

APPLICANT'S DECLARATION
1 DO YOU HAVE ANY RELATIVE/FRIEND WORKING IN LUXXO GROUP OF COMPANIES? YES/NO

2 ARE YOU UNDER ANY CONTRACTUAL BOND WITH YOUR CURRENT EMPLOYER? YES/NO

3 HAVE YOU EVER BEEN TERMINATED OR DISMISSED FROM A PREVIOUS EMPLOYMENT? YES/NO

4 HAVE YOU EVER BEEN DETAINED, CHARGED OR CONVICTED IN ANY COURT OF LAW? YES/NO

5 ARE YOU INVOLVED IN ANY CIVIL LAWSUITS OR THE SUBJECT ON AN INVESTIGATION? YES/NO

6 ARE YOU CURRENTLY UNDERGOING BANKRUPTCY, PROCEEDINGS OR AN UNDISCHARGED BANKRUPT? YES/NO

7 HAVE YOU BEEN EXPELLED OR DISALLOWED TO ENTER ANY COUNTRIES? YES/NO

8 DO YOU POSSESS YOUR OWN VEHICLE? YES/NO

9 DO YOU HAVE A VALID DRIVER'S LICENSE? IF YES, PLEASE SPECIFY 'CLASS' AWARDED :______________________________
YES/NO

ARE YOU CURRENTLY ATTENDING ANY COURSE?

10 YES/NO
IF YES, PLEASE STATE NAME OF COURSE AND INSTITUTION :___________________________________________________
HAVE YOU BEEN HOSPITALISED BEFORE?
11 YES/NO
IF YES, PLEASE STATE :__________________________________________________________________________________
HAVE YOU UNDERGONE ANY MEDICAL SURGERY PREVIOUSLY?
12 YES/NO
IF YES, PLEASE STATE :__________________________________________________________________________________
ARE YOU ON ANY LONG TERM MEDICATION?
13 YES/NO
IF YES, PLEASE STATE :__________________________________________________________________________________
ARE YOU CURRENTLY ENGAGED IN ANY PERSONAL BUSINESS OR PART-TIME EMPLOYMENT?
14 YES/NO
IF YES, PLEASE STATE :__________________________________________________________________________________

Page 3
I, ______________________________________ NRIC : ________________________ hereby declare that the
information given herein is true and correct to the best of my knowledge and belief.

I further declare that I understand that as the information given herein forms the basic of my engagement by
the Company. I will be liable to instant dismissal should it be discovered that this information is not correct or
true in any particular point notwithstanding any provision in my contract of service with the Company.

__________________________ ____________________
APPLICANT'S SIGNATURE DATE

FOR LUXXO USE ONLY

EVALUATION
Rating Codes : 4 - Good 3 - Average 2 - Below Average 1 - Poor

Factors Rating Comments by Head of Dept Rating Comments by HR

General Appearance

Maturity

Attitude & Initiative

Alertness

Language Command & Comprehension

Employment Experience for Position

Qualifications / Training

Background for Position

Job Knowledge

Personality

Job / Stability

OVERALL RATING

Page 4
 REMARKS :
APPROVED BY HOD

Interviewed by Head of Department :

_________________________________
Signature & Date :

DECISION FOR
KIV Reject Hire
2ND INTERVIEW

Job Title :__________________________________ Commencement Date :___________________________________

Probation :__________________________________ Department :___________________________________

Basic Salary :__________________________________ General Comments :___________________________________

FINAL APPROVAL
Approved By :

__________________________________
GM / CEO / DIRECTOR

REMARKS :
ACCEPTED BY

Review & Accepted by Human Resource Department :

_________________________________
Signature & Date :

Page 5