VITAL BIZ SOLUTIONS LTD

A. EMPLOYEE HISTORY / PERSONAL INFORMATION

1. Personal contact information

Employee Name:

Address:

City:

Date of birth:

Telephone No: email address:

Marital status:

Blood Group:

Physical Address (Residence): Estate:

Street: Hse No:

 Education Background

Academic Achievement:

a) “O” Level Yes/No Grade Achieved:

b) University Level (State Degree Course and Grade Attained)

 Professional Qualifications:

State any other professional courses undertaken i.e. CPA, Secretarial etc and the grades and levels attained

Other Skills Attained

 Other Details:

NSSF No : NHIF No : KRA PIN No :

ID. No :

 Bank Account Details: Account Name: Bank : 

Branch: Account No:

2. Emergency Contact Information: (Next of Kin)

Emergency Contact: Contact Tel:

Relationship to you:

Physical Address (Residence) :

3. Referee Contact Information:

a) Professional Referee : Contact Tel:

b) Personal Referee (A family Member) : Contact Tel:

4. Hobbies and extra-curricular Involvement:

 VITAL BIZ SOLUTIONS LTD

Please return completed form to the office manager.

All information provided shall be kept confidential, although we ask that you allow us to put your home phone
number on our internal contact sheet.

Please sign here to confirm the above

Signature Date

B. MEDICAL FORM

Have you ever been treated for or experienced any of the following?

YES NO
a.) Disease or disorder of eyes, ears, nose or throat?

b.) Dizziness, fainting, convulsions, headache, speech defeat,

Paralysis or stroke; mental or nervous disease or disorder
c.) Shortness of breath, persistent hoarseness or cough, blood spitting
Bronchitis, pleurisy, asthma, tuberculosis or chronic respiratory or lung disease?
d.) Chest pain, high blood pressure, rheumatic fever, heart attack or
Other disease of the heart of blood vessels?
e.) Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, colitis, or
Other disease of the stomach, intestines, liver or gall bladder.
f.) Are you expectant?(female)
g.) Disease of skin, lymph glands, tumor or cancer?

h.) Allergies, Anaemia or other disease of the blood

i.) Excessive use of alcohol

j.) Have you within the past 12 months smoked cigarettes, cigars, pipes
Or used other tobacco-related products?
k.) Do you have any of the following which are unexplained:
Fatigue, weight loss, Diahorrea or unusual skin lesions?
l.) Any mental or physical disease or disorder not listed above?

m.) Been advised to have any diagnostic test, surgery which was not completed?

Please sign here to confirm the above

Signature

Date