MLHA/ DES FORM 1
MINISTRY OF LABOUR AND HOME AFFAIRS
DEPARTMENT OF EMPLOYMENT SERVICES
INTERNSHIP APPLICATION FORM
1. PERSONAL DETAILS:
MR/MS/MRS/DR: LAST NAME: KEABI
...............................MIDDLE NAME.................................FIRST NAME..............................
NATIONAL IDENTITY NUMBER: ...........................................................................................................................................
DATE OF BIRTH: DAY............................ MONTH..........................................YEAR...........................................................
GENDER (Please tick where applicable) MALE FEMALE
MARITAL STATUS (Please tick where applicable) SINGLE MARRIED
DIVORCED WIDOWED
2. CONTACT DETAILS:
EMAIL ADDRESS _____________________________ MOBILE / SMS NUMBER __________________________________
WHATSAPP NUMBER _________________________________________________________________________________
POSTAL ADDRESS ____________________________________ PHYSICAL ADDRESS ____________________________
3. NEXT OF KIN:
SURNAME: ____________________________ FIRSTNAME (S): ________________________________________________
RELATION OF NEXT OF KIN: PARENT/GUARDIAN/SPOUSE: _________________________________________________
EMAIL ADDRESS ________________________________ FAX NUMBER _________________________________________
TELEPHONE NUMBER ___________________________ MOBILE NUMBER ______________________________________
WHATSAPP NUMBER _________________________________________________________________________________
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MLHA/ DES FORM 1
4. EDUCATION LEVEL: (e.g. Junior Certificate; BGCSE; Certificate; Diploma/Degree/Masters etc.)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Program Name: ________________________________________ Major: ____________________________________
Name of Institution: ____________________________________ Completion Date: _____________________________
5. DISABILITY STATUS: (This section should only be filled by people living with disability)
Are you living with disability? Yes No
If Yes attach certified copy of card for people living with disability or letter from competent authority.
Name of Village................................................................................District..........................................................................
6. REMOTEL AREA COMMUNITIES:
(This section should only be filled by beneficiaries of the Remote Area Development Programme)
Are you from a remote area community? Yes No
If Yes
Name of Village _____________________________________ District _________________________________________
7. FIELD OF INTEREST:
Preferred field of interest ______________________________________________________________________________
8. PREFERRED LOCATION: (Place of service where own accommodation is available)
i. ______________________________________________________________
ii. ______________________________________________________________
iii. ______________________________________________________________
9. STATE YOUR COMPETENCIES:
i. _______________________________________________________________
ii. _______________________________________________________________
iii. _______________________________________________________________
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MLHA/ DES FORM 1
10. SUPPORTING DOCUMENTS
i) CERTIFIED COPIES OF EDUCATIONAL CERTIFICATES
ii) CERTIFIED COPIES OF TRANSCRIPTS WHERE
NECESSARY
iii) CERTIFIED COPIES OF NATIONAL REGISTRATION
(OMANG)
11. AFFIRMATION/DECLARATION BY APPLICANT
I do declare or affirm that the information contained is true and correct to the best of my knowledge and belief. I am aware that
the Department reserves the right to reject my application or terminate enrollment should the information contained above be
found to be incorrect or not true.
I also declare that I have never served in the National Internship Programme before.
SIGNATURE.........................................................................DATE...........................................................................................