PRIVATE & CONFIDENTIAL

IMU EDUCATION SDN BHD

Photo

INTERNATIONAL MEDICAL UNIVERSITY

No. 126, Jalan Jalil Perkasa 19, Bukit Jalil
57000 Kuala Lumpur, Malaysia.
Tel: +603-86567228 Fax: +603-86568836
Website: www.imu.edu.my
(For Academic Appointments )
STAFF APPOINTMENT APPLICATION FORM
Please complete the application form in BLOCK LETTERS and enclose a passport
size photograph. No spaces should be left blank. If it is not applicable write N/A or
NIL. Copies of Certificates or testimonials should be attached. The originals should
be brought to the interview.

Post applied for : PROFESSOR IN PATHOLOGY (HISTOPATHOLOGY)

PERSONAL PARTICULARS
Name in full
MAXIMO B. AXIBAL, JR.
Postal Address
1- C SULATAN ST. , MANDALUYONG CITY
Tel No. (Home) :
533Tel No. (Office) :
6733
Mobile No.:

E-Mail

0917- axibalmdpath@yahoo.com.ph

8400- 261
Date & place of birth: AUGUST 1, 1958

Age: 54

Sex : MALE

Single
/
Married
Divorced
Marital
Status :
Please ()
tick
Country of Domicile : PHILIPPINES
Citizenship : FILIPINO
I/C No. (Color) or Passport No.
EB3193245
Language
Proficiency:

Date & Place issued:

28 JUL 11/ DFA MANILA
TAGALOG; Religion:
ROMAN

ENGLISH

CATHOLIC

Hobbies/Interests:

READING
BOOKS
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International Medical University

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FAMILY DETAILS
Spouses Name: MARIA GERTRUDES C. PICA- AXIBAL
Profession: INDUSTRIAL PHYSICIAN
Employer: ANGELUS MEDICAL CLINIC
No. of Children : SIX
Childrens Ages : 26, 24, 22, 20, 19, 18

Fathers Name : MAXIMO R. AXIBAL, SR. (DECEASED)

Profession: LAWYER
Employer: N/A

Mothers Name : CRISTINA B. BOSQUE- AXIBAL (DECEASED)

Profession: TEACHER
Employer: N/A

Brothers:

Sisters:

ROMEL

HAZEL

FERDINAND

NELIA

ELMER

EDUCATION (State School/College/University attended with dates):

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International Medical University

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DIPLOMA/DEGREES (state areas of concentration/specialization)

Diploma/Degree/University

Month & Year Awarded

Specialization

TITLE OF MASTERS/DOCTORATE DISSERTATION (PLEASE ATTACH ABSTRACT):

INDICATE SPECIFIC AREAS OF TEACHING:

LANGUAGES FLUENT IN: TAGALOG; ENGLISH

LIST AREAS OF RESEARCH INTEREST:

PROFESSIONAL QUALIFICATIONS (with dates and other relevant information):

SCHOLARSHIPS & OTHER ACADEMIC AWARDS (dates and awarding body):

MEMBERSHIPS (names of Association/Society, etc. and date joined):

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International Medical University

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WORKING EXPERIENCE*
Post Held
Employer
Name of Post
Name and Full Address

Dates
From
Until

* For each post held, please describe, briefly job specifications and responsibilities

Present Salary RM

Expected Salary RM

PUBLICATIONS & PRESENTATIONS (please append):

PUBLIC/COMMUNITY SERVICES:

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International Medical University

Period of Notice
required

PRIVATE & CONFIDENTIAL

REFEREES (Please give title, full name, address, e-mail and telephone numbers of
3 referees who can comment on your academic and working experience)

1.
2.
3.

Based on the information you have received from us and your own background
experiences, briefly describe how you can contribute effectively to the IMU.

ADDITIONAL INFORMATION
Do you know anyone in International Medical University (IMU)?

YES

NO

NO

NO

(If yes, state name, relationship) _______________________________________

Have you applied to IMU before?

YES

(If yes, state position & year/month of application)________________________

Have you ever been charged and/or convicted in any criminal
court of law?
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International Medical University

YES

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(If yes, please provide details)

______________________________________

Have you ever been sued and /or convicted for bankruptcy?
(If yes, please provide details)

YES

NO

NO

______________________________________

Have you any active interest in any business undertaking,

YES
including family business?
(If yes, please give details) ____________________________________________
MEDICAL AND PHYSICAL STATUS

Have you suffered from or are you currently suffering from

/
YES
serious illness?
(If yes, please provide exact details): STATUS POST ACUTE MYOCARDIAL
INFACTION WITH FIVE STENT
ANGIOPLASTY (YEAR 2008)
Are you suffering from any physical disabilities?
YES /

NO

NO

(If yes, please provide exact details)____________________________________

I declare that the information given in this application is true and accurate and
I understand that it is a condition of employment that I satisfactorily pass a
medical examination. I understand that any misrepresentation of facts given
herein will be sufficient cause for IMU to summarily terminate my appointment
if, after engagement, the particulars given in this form are found to be false or
incorrect.
Enclosed are copies of my education/professional qualification
certificate/diploma/degree and/or appropriate recommendation letters.

____________________________

_______________________________________________

Date :

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International Medical University

Signature
:
Name: