Agostini's Limited

and its Subsidiary Companies AFFIX

GROUP APPLICATION FORM HR 16b PHOTO

PERSONAL PARTICULARS

SURNAME OTHER NAMES FIRST NAME

GENDER Male
MAIDEN NAME NATIONALITY Female
(if married)

DATE OF BIRTH MARITAL STATUS MOBILE PHONE NO.

______________________ __________________________
HOME PHONE NO. EMAIL ADDRESS

PERMANENT ADDRESS MAILING ADDRESS

DEPENDENTS (SPOUSE/CHILDREN)
Name Date of Birth Relation

EMERGENCY CONTACTS
Name Address Home Tel # Work Tel # Relation

Identification #: N.I.S. #:
Driver’s Permit #: B.I.R. #:

Do you own a vehicle? Y[ ] N[ ] Vehicle Reg. #:

Have you ever applied to / worked at Agostini's Limited before? Y[ ] N[ ] When? To Whom / With?

Name any relatives in our employ:

Have you any relatives in the Distribution trade? (Please specify)

Name Company Position
1.
2.

Please give details of any business interest that you may be involved in directly or indirectly?

EDUCATION
Name & Address of Institution From To Examination Results

HR 16b – last reviewed June ‘10 1

Do you have any special skills, training, knowledge, licenses and expertise? Please explain.

Computer Literacy (Please tick) MS Word [ ] MS Excel [ ] MS PowerPoint [ ] MS Access [ ]

Other (Please Specify) _______________

MEDICAL

Date of Last Physical: ___________ Purpose: _______________ Results: _______________

Do you have any physical defects, serious injury or chronic illness, such as hernia, stomach ulcer, diabetes, heart
defect, high blood pressure, etc? If so explain.

PREVIOUS EMPLOYMENT (Please start with the most recent job first)

Did you
Name, Title &
Name & Address of resign of
Dates Tel # of Last Your Duties Earnings
Company your own
Supervisor
accord?

REFERENCES (Please give the names of two work related references (not relatives or close personal friends), one of
whom should be from your latest employer)

Name Address Tel # Occupation

I hereby certify the above to be true and correct. I understand that if subsequent to engagement, any particulars
furnished by me are found to have been false within my knowledge, I shall be liable to dismissal. I authorise you to
make such inquiries of my personal, employment, financial and medical history as may be necessary to arrive at an
employment decision.

Applicant Signature Date of Application

FOR OFFICIAL USE ONLY

POSITION
DEPARTMENT &
COMPANY
STARTING DATE

SALARY

HR 16b – last reviewed June ‘10 2