156043

PUBLIC SERVICE OF NAMIBIA

APPLICATION FOR EMPLOYMENT
1. This form must be completed by the applicant in full except where it is not applicable. 2. Curriculum Vitae must be attached by all applicants. 3. All
PLEASE
applicants must attach certified copies of educational certificates and identification documents.4. The Health Questionnaire must be completed in full
NOTE: and attached to this form. 5. Mark with an “X” where appropriate. 6. Applicants must use one application form for each position applied for. Failure to
comply with the above mentioned requirements, will result in immediate disqualification.
A. EMPLOYMENT DESIRED

1. Position applied for: 2. Office/Ministry/Agency/Regional Council in order of preference:

.................................................................................................................... .............................................................................................................
.................................................................................................................... .............................................................................................................
3. Duty station: 4. When can you assume duty? .............................................................
.................................................................................................................... 5. If post has been advertised, Reference:
.................................................................................................................... Advertised in........................................................................................
Date......................................................................................................

B. PERSONAL PARTICULARS
1.a) Surname (in block letters) 9. Gender/Marital Status

b) (maiden name if applicable) (in block letters)

2. First names (in block letters)

(i) Male
3. Namibian Identity Number: 4. Date of birth:

6. Work Permit No.:....................................... (ii) Female

5. Passport No.: …………………………………………………………… (If applicable)
Citizenship: ................................................................. (iii) Married
7. Postal Address: 8. Residential Address:
........................................................................................... ........................................................................
........................................................................................... ........................................................................ (iv) Single

10. Contact details. :

Home No.: ...............................................Mobile No.:………………………………………………… Work No.: .................................... Fax no...........................
Email:……………………………………………................................................................................ Fax2mail:.............................................................................
Name of alternative contact person:………………………………………………………………………….. Telephone/Mobile No:…………………………………………………….
11. Are you a person with disability? Yes No (If yes, provide details under Part. C of the Health questionnaire)

12. Additional information

12. 1 Have you ever been convicted of a criminal offense? No Yes

12. 2 Is a criminal or any other case pending against you? No Yes
12. 3 Have you ever been dismissed from employment? No Yes
12.4 Have you ever been boarded on medical grounds? No Yes
If yes in any of these, furnish full particulars on a separate sheet.

C. CURRENT EMPLOYMENT PARTICULARS (Applicants in the Public Service only)

1. Office/Ministry/Agency/Regional Council:……………....…………………................................ 2. Duty Station:…………………….…............................................
3. Job Designation: ……………………………………...................................................................... 4. Grade:................................................................................
5. Date of Appointment in current post (dd-mm- yyyy).....................................................................................................................................................
6. Scale of salary:…………………………………………………………………………..……………………………… 7. Salary notch:…………………………………………………………………..
8. Is your probation in the current post confirmed? Yes No If yes, attach the confirmation letter.
 156043
D. LANGUAGE PROFICIENCY
State “good”, “fair”, “poor” in the appropriate spaces
Other (Specify)
English
Speak
Read
Write

E. QUALIFICATIONS (1. Attach relevant documents [Link] foreign qualifications must be evaluated by Namibia Qualifications Authority (NQA))
1. Name of educational Certificates and/or ALL SUBJECTS. Underline major subjects. In the case of
Month and year obtained
institute or and centre diplomas obtained typing and shorthand, state language as speed
1.1 School State highest
qualification only ..............................................................................................
..............................................................................................
..............................................................................................
1.2 Universities, Colleges State all qualifications
and other institutions ..............................................................................................
..............................................................................................
..............................................................................................
2. State field of further study (if any):

3. Number of years apprenticeship successfully completed: Agreement No: Institution:

4. If your profession or occupation requires statutory registration, state date and particulars of registration:

F. EXPERIENCE
From To
Employer Post held Reason for Change
Day Month Year Day Month Year

............................................. .......................................... ......... .......... ......... .......... .......... .......... .......................................

............................................. .......................................... ......... .......... ......... .......... .......... .......... .......................................

............................................. .......................................... ......... .......... ......... .......... .......... .......... .......................................

............................................. .......................................... ........ .......... ......... ......... .......... .......... .......................................

G. CONTRACTUAL OBLIGATIONS
Do you have any contractual obligations, i.e. study, bursaries, etc.? (If so, describe)

.....................................................................................................................................................................................................................................

H. DECLARATION
I I do hereby declare that the above particulars are complete and correct and I have not withheld any required information.

....................................................................... .......................................................
Signature Date
NOTE: A false declaration will disqualify your application or may lead to your discharge if discovered after your appointment

FOR OFFICIAL USE

Particulars in B1 to 6, certified correct.

................................................................... .............................................................. ..................................

Signature Rank Date
 156094

PUBLIC SERVICE OF NAMIBIA

HEALTH QUESTIONAIRE
FOR OFFICIAL USE
Accepted / rejected in accordance with directions
THIS FORM MUST BE COMPLETED BY
ALL APPLICANTS Signature:.............................................................................
Post designation: .................................................................
Date: ………….........................................................................
OMA/RC:…………………………………………………………………………..

A
1. Surname (in block letters): 5. Identity No.:

2. First Names:

3. Age (years): 4. Height (cm): 6. Body mass (kg):

B.
Mark with a “X” in the
Are you suffering, or have you If any answer is “Yes”, give details of the nature, severity, date and duration
appropriate column
ever suffered from of the illness
Yes No

..............................................................................................................................
1. Any skin disease?
..............................................................................................................................

Yes No
2. Any condition affecting the ..............................................................................................................................
skeleton and/or joints?
..............................................................................................................................

Yes No
.
3. Any condition affecting the
eyes, ears, nose or teeth? ..............................................................................................................................
..............................................................................................................................

Yes No
4. Any condition affecting the
..............................................................................................................................
heart or circulatory system?
..............................................................................................................................

Yes No
5. Any condition affecting the ..............................................................................................................................
chest or respiratory system?
..............................................................................................................................
Please turn over . . . /
 156094

Are you suffering, of have you Mark with a “X” in the If any answer is “Yes”, give details of the nature, severity, date and duration
ever suffered from appropriate column of the illness
Yes No
6. Any condition affecting the ..............................................................................................................................
digestive system?
..............................................................................................................................
Yes No
7. Any condition affecting the
..............................................................................................................................
urinary system and/or genital
or reproductive organs? ..............................................................................................................................
Yes No
8. Any condition affecting the
..............................................................................................................................
nervous system or mental
illness? .............................................................................................................................
Yes No
. ............................................................................................................................
9. Any other illness?
..............................................................................................................................

C.
Yes No
1. Do you have any sensory impairment e.g. hearing, speech or sight?

2. Do you have any disability?

(physical , mental or any other impairment that substantially restricts you in one or other way of an individual's major life
activities)

IF YES, GIVE DETAILS OF THE NATURE AND SEVERITY OF THE DISABILITY:

D.
Yes No
Have you undergone any surgery/operation(s)?

IF YES, GIVE DETAILS OF THE NATURE AND DATE OF THE OPERATION(S)

E.

I do hereby declare that the above information is true and correct and that I have not withheld any information regarding my health.

.............................................................................................................. ............................................
Signature Date