Fillable Form 1.: Personal History Application for Appointment (Brookhaven National Laboratory)

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Form 1.: Personal History Application for Appointment (Brookhaven National Laboratory)

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Application for Appointment
Personal History
INSTRUCTIONS
Please provide a cover letter along with your completed Personal History
form. Please answer each question clearly and completely. Read carefully
and follow all directions.
TYPE OR PRINT IN INK.
Please do not write in this space
1.
POST(S) APPLIED FOR (or preferred field of work):
PERSONAL INFORMATION
2.
3.
4.
Family Name First & Middle Name Maiden Name, if any
5.
6.
7.
8.
Date of Birth (yyyy/mm/dd) Place of Birth Marital Status Gender
9.
10.
11.
Nationality at Birth Present Nationality Second Nationality, if any
CONTACT INFORMATION
12.
13.
Permanent Address (Street, City, Country) Current Home Telephone No.
14.
15.
Present Address (Street, City, Country) Work Telephone No.
16.
17.
E-Mail Address Mobile Telephone No.
18.
EDUCATION - Give exact names of institutions and titles of degrees above secondary school, as they appear in the diploma(s). Please do not translate or equate
to other degrees.
Month/Year attended
from to
Degrees and Academic Distinctions
Main Course of Study Name, Place and Country
Please indicate if any of the studies specified above was not finished or is in progress and give reasons for any overlaps of study periods. If you wish, provide any other
information regarding your education that you consider relevant:
P-2E Rev.3 (Jan 04)
19.
EMPLOYMENT RECORD - Starting with your most recent post, list in reverse order every appointment you have had. Use a separate block for each post.
Include also service in the armed forces and note any period during which you were not gainfully employed. If you need more space, attach additional pages of the
same size.
From To Exact title of your post:
Type of business:
Name, address and phone number of present employer:
Name and title of present supervisor:
Have you any objections to our making enquiries of your present employer?
Yes / No
Number and kind of employees supervised by you:
Reason for leaving:
Total annual net income (after deduction of tax):
DESCRIPTION OF YOUR DUTIES:
From To Exact title of your post:
Type of business:
Name, address and phone number of employer:
Number and kind of employees supervised by you:
Reason for leaving:
Total annual net income (after deduction of tax):
DESCRIPTION OF YOUR DUTIES:
From To Exact title of your post:
Type of business:
Name, address and phone number of employer:
Number and kind of employees supervised by you:
Reason for leaving:
Total annual net income (after deduction of tax):
DESCRIPTION OF YOUR DUTIES:
From To Exact title of your post:
Type of business:
Name, address and phone number of employer:
Number and kind of employees supervised by you:
Reason for leaving:
Total annual net income (after deduction of tax):
DESCRIPTION OF YOUR DUTIES:
20. If you have had more jobs, please describe them
below. Also, provide reasons for any overlaps of work periods.
21.
DEPENDANTS - If you have dependants give the following information:
Name
Date of Birth
(Year/Month/Day)
Relationship Name
Date of Birth
(Year/Month/Day)
Relationship
If you wish, provide any other information regarding your dependants that you consider relevant:
22.
KNOWLEDGE OF LANGUAGES:
What is your mother tongue?
Please specify other languages you know and indicate your level of knowledge by using the following keys: LIMITED (LIM) = Limited conversation, reading of
newspapers, routine correspondence. WORKING KNOWLEDGE (WK) = Engage freely in discussions, read and write more complex material. FLUENT (FL) = Speak,
read and write nearly as well as mother tongue.
No. Language Speak Read Write
1.
2.
3.
4.
5.
6.
7.
8.
23.
PUBLICATIONS (for professional or scientific posts only)
List any significant publications you have written.
24.
OFFICE SKILLS (For clerical posts only) - Indicate speed in words per minute. Add other languages if necessary.
English
Typing
List special clerical/secretarial skills you possess and any office machine or equipment you can use:
25.
COMPUTER SKILLS
Please indicate and comment on your computer knowledge in the areas listed below. When indicating your level of knowledge, use the following keys: FAIR = limited
experience. WORKING KNOWLEDGE = regular use of the software and ability to apply it to meet the requirements of the job. PROFICIENT = advanced user; able to
perform complex tasks. If you have no knowledge of any area, leave the corresponding field blank.
Word Processing:
Spreadsheets:
Presentation/Desktop publishing:
Databases:
Internet:
E-Mail/Communication:
Programming:
Other software:
Computer hardware/Special equipment:
26. List membership in professional societies and activities in civic, public or international affairs.
27.
MISCELLANEOUS
Have you taken up legal permanent residence status in any country other than that of your nationality?
Yes / No
Have you taken any legal steps towards changing your present nationality?
Yes / No
If the answer to either question is yes, explain fully:
Have you ever been arrested, indicted or summoned into court as a defendant in a criminal proceeding or
convicted, fined or imprisoned for the violation of any law (excluding minor traffic violations)?
Yes / No
If yes, give full particulars of each case in an attached statement.
State any other relevant facts. Include information regarding any residence outside the country of your nationality.
Where did you learn about job opportunities at the IAEA?
28.
WORK CONDITIONS
Have you previously worked for the IAEA?
Yes / No
If so, enter personnel number:
Have you previously submitted an application for employment with the IAEA?
Yes / No
If so, when?
Would you accept employment for less than six months?
Yes / No
29.
Are any of your relatives employed by IAEA or any other international organization?
Yes / No
If the answer is yes, give the following information:
Name Relationship Name of international organization
Entry into the service of the International Atomic Energy Agency may entail assignment and travel to any area of the world in which the Agency might have
responsibilities. If you have any disabilities which might limit your prospective field of work or your ability to travel by air, please describe:
30.
REFERENCES - List three persons, not related to you, who are familiar with your character and qualifications. DO NOT repeat names of supervisors listed in
the employment record.
Full name Full address, phone number and e-mail address Business or occupation
31. IMPORTANT
- Please provide any other information that you consider important for the evaluation of your candidature:
32. I certify that the statement made by me in answer to the foregoing questions is true, com
plete and correct to the best of my knowledge and belief. I understand that
any misrepresentation or material omission made on a Personal History form or other document requested by the IAEA renders a staff member of the IAEA liable
to termination or dismissal.
Date:
Signature:
N.B. You may be requested to supply documentary evidence which supports the statements you have made above. Do not, however, send any documentary evidence until you have been asked to do
so by the Agency and, in any event, do not submit the original texts of references or testimonials unless they have been obtained for the sole use of the Agency. While you may rest assured that
your candidature will be carefully examined, receipt of this form will not necessarily be acknowledged. Any further correspondence will be initiated by the Agency.
T H E M A X I M U M P E R I O D O F V A L I D I T Y F O R A P E R S O N A L H I S T O R Y F O R M I S T W O Y E A R S
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Form 1.: Personal History Application for Appointment (Brookhaven National Laboratory)

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Completed 25 January 2021

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