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IMU EDUCATION SDN BHD Photo

INTERNATIONAL MEDICAL UNIVERSITYNo. 126, Jalan Jalil Perkaa 1!, "#ki$ Jalil

%&''' (#ala L#)*#r, Mala+ia.Tel -6'/06%6&220 a -6'/06%60063e4i$e 555.i)#.e#.)+

(For Academic Appointments )

STAFF APPOINTMENT APPLICATION FORM

Please complete the application orm in BLOCK LETTERSand enclose a passportsi!e photo"raph# No spaces sho$ld %e let %lan# I it is not applica%le 'rite NA orNIL# Copies o Certicates or testimonials sho$ld %e attached# The ori"inals sho$ld%e %ro$"ht to the inter*ie'#

Post applied or + PROFESSOR IN PATHOLOGY (HISTOPATHOLOGY)

PERSONAL PARTICULARSName in $ll MAXIMO B. AXIBAL, JR.Postal Address 1- C SULATAN ST. , MANDALUYONG CITYTel No# (,ome) + 533-

!33

-o%ile No#+ "#1!-

$%""- &1

Tel No# (O.ce) +

E/-ail +

'*'+'/02'0.4.0

Date & place o %irth+ AUGUST 1, 1#5$ A"e+ 5% 0e1 + MALE

-arital0tat$s +

Single / Married Divorced

Please ()ticCo$ntr2 o Domicile + PHILIPPINES Citi!enship + FILIPINO

IC No# (Color) or Passport No#

EB31#3&%5

Date & Place iss$ed+

&$ JUL 11 DFA MANILALan"$a"e Procienc2+ TAGALOG6

ENGLISH

Reli"ion+ ROMAN

CATHOLIC

,o%%iesInterests+

READING

BOOKS

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FAMILY DETAILS

0po$se3s Name+ MARIA GERTRUDES C. PICA- AXIBAL

Proession+ INDUSTRIAL PHYSICIAN

Emplo2er+ ANGELUS MEDICAL CLINIC

No# o Children + SIX

Children3s A"es + &, &%, &&, &", 1#, 1$

Father3s Name + MAXIMO R. AXIBAL, SR. (DECEASED)

Proession+ LA7YER

Emplo2er+ NA

-other3s Name + CRISTINA B. BOS8UE- AXIBAL (DECEASED)

Proession+ TEACHER

Emplo2er+ NA

4rothers+

ROMEL

FERDINAND

ELMER

0isters+

HA9EL

NELIA

EDUCATION (0tate 0choolColle"e5ni*ersit2 attended 'ith dates)+

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DIPLOMADEGREES (state areas o concentrationspeciali!ation)

DiplomaDe"ree5ni*ersit2 -onth & 6ear A'arded 0peciali!ation

TITLE OF MASTERSDOCTORATE DISSERTATION (PLEASE ATTACH ABSTRACT):

INDICATE SPECIFIC AREAS OF TEACHING:

LANGUAGES FLUENT IN: TAGALOG6 ENGLISH

LIST AREAS OF RESEARCH INTEREST:

PROFESSIONAL 8UALIFICATIONS (;/0 '/

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7ORKING EXPERIENCEP=/ H

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REFEREES(Please "i*e title7 $ll name7 address7 e/mail and telephone n$m%ers o: reerees 'ho can comment on 2o$r academic and 'orin" e1perience)

1.

2.

3.

4ased on the inormation 2o$ ha*e recei*ed rom $s and 2o$r o'n %ac"ro$nde1periences7 %rie82 descri%e ho' 2o$ can contri%$te e;ecti*el2 to the I-5#

ADDITIONAL INFORMATION

Do 2o$ no' an2one in International -edical 5ni*ersit2 (I-5)< 6E0 NO

(I 2es7 state name7 relationship) =======================================

,a*e 2o$ applied to I-5 %eore< 6E0 NO

(I 2es7 state position & 2earmonth o application)========================

,a*e 2o$ e*er %een char"ed andor con*icted in an2 criminalco$rt o la'$alication

certicatediplomade"ree andor appropriate recommendation letters#

============================ ===============================================

Date + 0i"nat$re+Name+

F:Staff/Application Form/StaffApplicationFormFaculty/2010 !

International Medical University