LIBERTAS GENERAL INSURANCE COMPANY LIMITED
EMPLOYMENT / JOB APPLICATION FORM
PERSONAL INFORMATION
FULL NAME: Jafali.Dickson.Chizimba GENDER: Male
First Middle Last
ADDRESS: _____________________________________________________________
Residential Physical Address
Home Village T/A District
E-MAIL:Jamajafali@gmail.com PHONE: 098895820/0883434541__________________
DATE OF BIRTH (dd/mm/yyyy): ___________________ SEX: _____________________
NATIONAL IDENTITY NUMBER: ______________ EXPIRY DATE: ___________________
DATE AVAILABLE: __________________ DESIRED PAY: K___________ ☐ NET ☐ GROSS
POSITION APPLIED FOR: _________________________________________________
DO YOU HAVE ANY OF THESE HABITS? ☐ SMOKING ☐ ALCOHOL ☐ BETTING/GAMBLING
☐ NONE OF THE ABOVE
EMPLOYMENT ELIGIBILITY
ARE YOU LEGALLY ELIGIBLE TO WORK IN MALAWI? ☐ YES ☐ NO*
*IF NO, STATE WHY YOU ARE APPLYING FOR THIS JOB: __________________________
____________________________________________________________________________
HAVE YOU EVER WORKED FOR THIS EMPLOYER? ☐ YES* ☐ NO
*IF YES, WRITE THE START AND END DATES: ____________________________________
HAVE YOU EVER BEEN CONVICTED OF A FELONY? ☐ YES* ☐ NO
*IF YES, PLEASE EXPLAIN: ____________________________________________________
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EDUCATION
UNIVERSITY: ________________________ CITY / DISTRICT: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _________________________________________________
MODE OF STUDY: ☐ PHYSICAL ☐ ONLINE ☐ CORRESPONDENCE
UNIVERSITY: ________________________ CITY / DISTRICT: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _________________________________________________
MODE OF STUDY: ☐ PHYSICAL ☐ ONLINE ☐ CORRESPONDENCE
OTHER: _____________________ CITY / DISTRICT: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: ________________________________________________
MODE OF STUDY: ☐ PHYSICAL ☐ ONLINE ☐ CORRESPONDENCE
OTHER: _____________________ CITY / DISTRICT: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: ________________________________________________
MODE OF STUDY: ☐ PHYSICAL ☐ ONLINE ☐ CORRESPONDENCE
EMPLOYMENT HISTORY
(FROM CURRENT/MOST RECENT)
EMPLOYER 1: __________________________________________________________
Company / Individual
E-MAIL: __________________________________ PHONE: _____________________
ADDRESS: ____________________________________________________________
Physical Address
____________________________________________________________
P. O. Box District Country
STARTING PAY: K_________ ☐ NET ☐ GROSS ENDING PAY: K_________ ☐ NET ☐ GROSS
JOB TITLE: ______________ RESPONSIBILITIES: _____________________________
FROM: _____________________ TO: _____________________
REASON FOR LEAVING: _______________________________________________________
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EMPLOYER 2: __________________________________________________________
Company / Individual
E-MAIL: __________________________________ PHONE: _____________________
ADDRESS: ____________________________________________________________
Physical Address
____________________________________________________________
P. O. Box District Country
STARTING PAY: K_________ ☐ NET ☐ GROSS ENDING PAY: K_________ ☐ NET ☐ GROSS
JOB TITLE: ______________ RESPONSIBILITIES: _____________________________
FROM: _____________________ TO: _____________________
REASON FOR LEAVING: _______________________________________________________
EMPLOYER 3: __________________________________________________________
Company / Individual
E-MAIL: __________________________________ PHONE: _____________________
ADDRESS: ____________________________________________________________
Physical Address
____________________________________________________________
P. O. Box District Country
STARTING PAY: K_________ ☐ NET ☐ GROSS ENDING PAY: K_________ ☐ NET ☐ GROSS
JOB TITLE: ______________ RESPONSIBILITIES: _____________________________
FROM: _____________________ TO: _____________________
REASON FOR LEAVING: _______________________________________________________
REFERENCES
(PROFESSIONAL ONLY)
FULL NAME: _______________________________ RELATIONSHIP: ______________
First Last
COMPANY: ________________________________ TITLE: ______________
E-MAIL: __________________________________ PHONE: _____________________
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FULL NAME: _______________________________ RELATIONSHIP: ______________
First Last
COMPANY: ________________________________ TITLE: ______________
E-MAIL: __________________________________ PHONE: _____________________
FULL NAME: _______________________________ RELATIONSHIP: ______________
First Last
COMPANY: ________________________________ TITLE: ______________
E-MAIL: __________________________________ PHONE: _____________________
RELATED PARTIES
ARE YOU RELATED TO ANY PERSON HOLDING A POSITION WITH THIS EMPLOYER?
☐ YES ☐ NO
NAME: _____________________ POSITION: _____________________
RELATIONSHIP: _____________________
BACKGROUND CHECK CONSENT
IF YOU ARE SUCCESSFUL WITH THIS APPLICATION, ARE YOU WILLING TO CONSENT
TO A BACKGROUND CHECK? ☐ YES ☐ NO
DISCLAIMER
Applicant understands that this is an Equal Opportunity Employer and committed to excellence
through diversity. In order to ensure this application is acceptable, please print or type with the
application being fully completed in order for it to be considered.
Please complete each section EVEN IF it is not applicable to you.
I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this
application leads to my eventual employment, I understand that any false or misleading
information in my application or interview may result in my employment being terminated.
SIGNATURE _________________________________ DATE _____________________
PRINT NAME _________________________________
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