KING FAISAL SPECIALIST HOSPITAL
AND RESEARCH CENTRE
EMPLOYMENT APPLICATION FORM
(General Organization)
APPLICANT’S PERSONAL
DETAILS
1. FULL NAME
First name: BUELLA Middle name: Last name: VARGHESE
2. Gender: 3. Marital status: 4. Current 5. Previous 6. Religion: (Must be listed,
nationality:INDIAN nationality:INDIAN NONE is ot acceptable):
Male Single:YES CHRISTIAN
Female:F Married Other,
(please specify):
7. Passport No. /Saudi national ID 8. Place of issue: 9. Date of 10. Date of birth:31.05 11. Place of birth:
1995 TAMILNADU
No.:p6433060 kerala issue:19.02.2017
12. ADDRESS
A. PERMANENT ADDRESS B. WORK ADDRESS
Telephone No.: Mobile No.: E-mail: Company name: Telephone No.: E-mail:
9605687747 buellavarghese5@g
mail.com
P.O. BoX: THEKKEKUTTU Postal code:686501 P.O. Box: Postal code:
HOUSE, VELLOOR,P.O
Country:INDIA City:PAMPADY, Street:PAMPADY Country: City: Street:
KOTTAYAM
13. Position applying for: STAFF 14. Date of availability: 15. Contract
NURSE Duration:
Permanent Locum:
1 year 2 years From:
To:
NO
16. Is spouse or parent working in Saudi No Yes
Arabia?
17. Is spouse or parent employee of KFSH&RC (Gen. Org.)? No Yes, please indicate I.D. No.:
NO
N
18. Have you previously been employed at KFSH&RC (Gen. O No Yes, please indicate I.D. No.:
Org.)?
19. If eligible for family status, do you intend to bring your family? No Yes, YESplease complete Item 20. (heck with your recruiter to confirm
eligibility)
20. DEPENDENTS – SPOUSE & CHILDREN (19 YEARS OLD AND BELOW)
NA DATE OF BIRTH NATIONALITY MA FEMALE
ME LE
1. (Spouse)
2. (Child-1)
3. (Child-2)
4. (Child-3)
5. (Child-4)
21. TRAVELLING & SECURITY
Point of origin: (Based on current nationality, nearest airport to home): KOCHIN Point of hire: (City traveling, if different from Point of Origin)
INTERNATIONAL AIRPORT
Location of nearest Saudi Arabian embassy: (if applicable)
Form 7366 V.1
Have you ever been convicted of any crime, felony, or misdemeanor?NO No Yes, please specify:
22. EMERGENCY CONTACT DETAILS
Name:T.C VARGHESE Relationship:FATHE TELEPHONE (INCLUDE AREA
CODE)
R Home: THEKKEKUTTU Mobile:9895111156 Work:BUSSINESS
HOUSE
P.O. Box: VELLOOR P.O, Postal code:686501 Country:INDIA City:PAMPADY, Street: PAMPADY
KOTTAYAM
23. EDUCATION / QUALIFICATIONS (STARTING FROM HIGH SCHOOL)
GRADUATI DEGRE
DEGR INSTITUTION NAME MAJOR/ SPECIALTY START
ON E
EE DATE
DATE CONFERR
ED
NIRMAL MEDICAL CENTER , 2012-2016 2016
1.B.SC NURSING COLLEGE OF NURSING ,
MUVATTUPUZHA
2.
3.
4.
24. PROFESSIONAL REGISTRATIONS/LICENSES/CERTIFICATION
CERTIFICATION NAME REGISTRATION/LICENSE RECEIVED DATE STAT
NUMBER US
Kerala nurses and midwives council Kl03201702267 21.02.2017 Valid, Until:
Expired: 20.02.2020
Valid, Until:
Expired
Valid, Until:
Expired
25. EMPLOYMENT HISTORY
(PLEASE LIST YOUR WORK EXPERIENCE BEGINNING WITH YOUR MOST RECENT
JOB)
EMPLOYMENT
COMPANY & EMPLOYER NAME ADDRESS CONTACT DETAILS PERIOD LAST POSITION TITLE
FROM T
O
Company: FORTIS HOSPITAL, Country:INDIA 01.08.2018 STILL
MULUND , MUMBAI, City WORKING
MAHARASHTRA Tel. No.:
:
MU
MB E-mail:
Immediate Manager:
AI
Stre
et:
MU
LU
ND
Country:
Company: City Tel. No.:
:
Stre
Immediate Manager: et: E-mail:
Country:
Company:
Tel. No.:
City:
Immediate Manager: Street: E-mail:
Country:
Company:
Tel. No.:
City:
Immediate Manager: Street: E-mail:
I affirm the information given above is true and correct. I understand that false or misleading information may result in my termination of employment from King Faisal
Specialist Hospital and Research Centre (General Organization).
In order for the KFSH&RC (Gen. Org.) to access and verify my educational background, professional qualifications and suitability for appointment, I hereby authorize
KFSH&RC (Gen. Org.) to make inquiries and consult with all persons, places of employment, education, malpractice carriers, state licensing boards, or other similar
government and non-governmental entities who may have information bearing on my moral, ethical and professional qualifications and competence to carry out the
privileges I have requested. I authorize release of such information and copies of related records and/or documents to KFSH&RC (Gen. Org.) officials. I authorize the
KFSH&RC (Gen. Org.) to disclose to such persons, employers, institutions, boards or agencies identifying other information about me sufficient to enable the
KFSH&RC (Gen. Org.) to make such inquiries. I release from liability all those who provide information to KFSH&RC (Gen. Org.) in good faith and without malice in
response to such inquiries.
I understand a physical examination is required and agree to undergo it. Should I fail to pass the physical examination or if for any reason it is determined that I am not
qualified for employment, I may not be employed and you shall not be held liable for loss or damage as a result.
Applicant’s Signature: …………………………………………………………… Date:…………20.07.2020……………
