Form

PHS

* indicates required items
*
*PERSONAL HISTORY STATEMENT :-
*1. Answer all questions to the best of your knowledge. If the question is not applicable, leave blank.(Whenever in doubt, do not hesitate to contact the person who served this form on you). Use separa
*DO NOT ATTEMPT TO COMPLETE THIS FORM UNTIL YOU HAVE READ THE FOLLOWING INSTRUCTIONS
*2. TYPE OR PRINT LEGIBLY
*3. DO NOT USE POST OFFICE BOX FOR ANY ADDRESS.
*4. CONSIDER EACHOF YOUR ANSWERS CAREFULLY ACCURATE COMPLETION OF THE FORM WILL FACILITATE CONSIDERATION OF YOUR APPLICATION.
*5. YOU ARE INFORMED THAT THE ACCURARY OF ANY STATEMENT MADE IN THIS APPLICATION MAY BE INVESTIGATED
*SEX
*SECTION 1: GENERAL PERSONAL AND PHYSICAL DATA
MALE	FEMALE

SURNAME
FIRST NAME
MIDDLE NAME(s)
DATE OF BIRTH
PLACE OF BIRTH
HOMETOWN
L.G.A
STATE
RERLIGION
DENOMINATION/ SECT
NICKNAMES
OTHER NAMES including MAIDEN NAME
PASSPORT NO
DATE OF ISSUE
PLACE OF ISSUE
Current Address(No. Stieet/Town/State)
TEL
Permanent Address. (No.Street,Town,State)
TEL
Height(m)
Weight(kg)
BUILD
COLOR OF EYES
COLOR OF HAIR
FACIAL\OTHER MARKS
COLOR OF SKIN
*.SECTION II. . MARTIAL STATUS
STATUS	SINGLE WIDOWED ENGAGED MARRIED DIVORCED REMARRIED SEPERATED

*PRESENT MARRIAGE
NAME OF SPOUSE/ fiance
SURNAME
FIRST NAME
MIDDLE NAME(s)
PROFESSION
RELIGION
DENOMINATION/ SECT
OCCUPATION
DATE OF BIRTH
PLACE OF BIRTH
ADDRESS
NATIONALITY
DATE OF MARRIAGE
PLACE OF MARRIAGE
HOMETOWN
L.G.A
STATE
*SECTION III NEXT OF KIN
*NAME OF NEXT OF KIN
FIRST NAME
SURNAME
MIDDLE NAME
RELATIONSHIP
Current Address(No. Street, Town,State)
HOMETOWN
L.G.A
STATE
PLACE OF BIRTH
RELIGION
DENOMINATION
PASSPORT NO
PLACE OF ISSUE
*SECTION IV. PARENTS DATA
*FATHER'S NAME
SURNAME
FIRST NAME
MIDDLE NAME(s)
DECEASED ?	YES NO

HOMETOWN
L.G.A
PLACE OF BIRTH
OCCUPATION
RELIGION
DENOMINATION/SECT
PASSPORT NO
PLACE OF ISSUE
Current Address(Name of Street, Town & State)
I Current Employer, Name and Address
*MOTHER'S NAME
SURNAME
FIRST NAME
MIDDLE NAME(s)
DECEASED ?	YES NO

HOMETOWN
L.G.A
STATE
PLACE OF BIRTH
OCCUPATION
DENOMINATION/SECT
PASSPORT NO
DATE OF ISSUE
PLACE OF ISSUE
Current Address(Name,Street,Town & State)
Current Employer, Name and Address
*SECTION V. BROTHERS AND SISTERS (INCLUDING HALF/STEP BROTHERS/SISTERS) DATA
*1) NAME OF SISTER OR BROTHER
SURNAME
FIRST NAME
MIDDLE NAME(s)
RELATIONSHIP
DATE OF BIRTH
PLACE OF BIRTH
PROFESSION
PRESENT EMPLOYER'S NAME AND ADDRESS
OCCUPATION
Current Address(Name,Street,Town & State)
QUALIFICATION ATTAINED
*2) NAME OF SISTER OR BROTHER
SURNAME
FIRST NAME
MIDDLE NAME(s)
RELATIONSHIP
DATE OF BIRTH
PLACE OF BIRTH
PROFESSION
PRESENT EMPLOYER'S NAME AND ADDRESS
OCCUPATION
Current Address(Name,Street,Town & State)
QUALIFICATION ATTAINED
*SECTION VI RELATIVES BLOOD, MARRIAGE OR ADOPTION,CLOSE ASSOCIATES WHO EITHER 1) LIVE ABROAD 2) ARE NOT NIGERIANS OR 3) WORK FOR A FOREIGN GOVERNMENT
NAME; FIRST NAME SURNAME AND LAST NAME
RELATIONSHIP
Place of Birth(City,State,Country)
CITIZENSHIP
Address of Country in which person resides
FOR HOW LONG?
PRESENT EMPLOYER'S NAME AND ADDRESS
FREQUENCY OF CONTACT
DATE OF LAST CONTACT
*SECTION VII. CHILDREN AND OTHER DEPENDENCIES
NAME OF CHILDREN\DEPENDENT
RELATIONSHIP
DATE OF BIRTH
PLACE OF BIRTH
CURRENT ADDRESS
*SECTION VIII EDUCATION DATA
*PRIMARY EDUCATION
*PLEASE, START WITH MOST RECENT SCHOOLS/INSTITUTIONS ATTEND,
NAME OF PRIMARY SCHOOL
ADDRESS OF SCHOOL
YEARS FROM
ATTENDED TO
QUALIFICATION OBTAINED
*SECONDARY SCHOOL EDUCATION
NAME OF SECONDARY
ADDRESS OF SCHOOL
YEARS FROM
ATTENDED TO
EXAM/CERT NO
QUALIFICATION OBTAINED
*UNIVERSITY /POLYTECHNIC/COLLEGE OF EDUCATION
NAME AND ADDRESS OF INSTITUTION
COURSE/DEPARTMENT
*DATE (MONTH , YEAR)
FROM
TO
MATRIC NO
DEGREE OBTAINED
YEAR OBTAINED
CLASS OF DEGREE
SOCIAL SECURITY NO FOREIGN STUDENT
*OTHER STUDIES/TRAINING IN SPECIALIZED SCHOOLS (E.G.MILITARY
NAME AND ADDRESS OF SCHOOL
TYPE OF STUDY
FROM
TO
QUALIFICATION OBTAINED
Can you drive?
Do you have a driver's license?(national?international)
Do you have or have ever had a professional License?
Indicate License And issuing body
DO YOU HAVE ANY SIGNIFICANT PUBLICATION IN YOUR NAME? IF YES INDICATE
Title
Publication
Publisher
*SECTION XI. NATIONAL YOUTH SERVICE
Call UP Number
Service Year
Service Period (From - To)
State of Deployment
Place of Primary Assignment
Address of Primary Assignment
Nature of Business
Title of Job
Name of Immediate Boss
State or National Award (specify)
Description of duties
were you discharged honorably ?	YES NO

If No, give reasons for extension
Place of extended service and assignment
*SECTION X. MILITARY SERVICE
MILITARY ORGANIZATION (Army, Navy, Airforce etc)
Service No
Branch or Corps
Entry Date
Exit Date
Rank Attained
Decorations
Status Reverse Etc
Have you been Discharged?	YES NO

Type of Discharge (Honorable Discharge, Release due to inability, Retirement for Age, Retirement from Service, Undue hardship, retirement for Combat Disability, Retirement for Physical Disability)
*SECTION XI. EMPLOYMENT HISTORY
1) Name of Employment
Address of Employer
Employer No if any
Type of Employment	Fulltime contract Casual part time

Period Employed (from-to)
Title of Job
Name of Business
starting salary
Last Salary
Name of Immediate Boss
Are you indebted to the employer	YES NO

Nature of Indebtedness
Reason for Leaving
Reason for Leaving
2) Name of Employer
Address of Employer
Employer No if any
Type of employment	Fulltime contract Casual part time

Type of employment	Fulltime contract Casual part time

Period Employed (from-to)
Title of Job
Name of Business
starting salary
Last Salary
Name of Immediate Boss
Are you Indebted to the Employer?	YES NO

Nature of Indebtedness
Reason for Leaving
*SECTION XII. PLACES OF RESIDENCE
*Give Details of actual places of residence (for the past 10 years)
Full address of residence
Date (From -To)
*SECTION XIII. REFERENCES (REFEREES) LIST
*References must be individuals(not relatives) who have known you for at least 2 yrs and must be resident in Nigeria
*List three( 3) persons who know you and can attest to your character
NAME; First,Middle & last
sex
Full Business Address
Full address of residence
Year Known
Telephone
Citizen acquired by	Birth marriage Naturalization

Ministry issuing Naturalization
Certificate No
Alien Reg No
Date of Arrival in Nigeria
Have you held previous Naturalization?	YES NO

If yes, state date
Last Nigeria Visa No, Date and Type
Date Visa Issued
Nigerian Passport Number and Expiration date if issued
Name of Country or Countries
*SECTION XV. CRIME RECORD
*NOTE: You must list ALL arrest information regardless of whether you have previosly listed or disclosed this inofrmation or whether the record in your case been closed or expunged
Date of Arrest
Name of offense
Name and Location of enforcement Agency
Name and location of court at home or abroad
Penalty Imposed
*SECTION XVI. CLUBS, SOCIETIES AND ORGANIZATION
Name and Chapter
Address (No, street, city, state, country)
Date of Membership (From -To)
Status
*SECTION XVII, LANGUAGE ABILITIES.
Language Type
Proficiency
Classification
*SECTION XVIII. FOREIGN TRAVEL / CONNECTIONS
Name of Country Visited
Purpose of Visit
Date Left Nigeria
Date Returned to Nigeria
*SECTION XIX. ECONOMIC & CREDIT HISTORY
*Do you have any registered company in or outrside nigeria in which you are directly or indirectly involved? if yes give details below
Name
Type e.g Limited Liability
Location or address
Nature of Involvement
State the Names and Addresses of your major Bankers.
*TAX DETAILS
*Give details of tax payment for the past 3 years
Year 1
Amount Paid
Tax Receipt No
Location of Payment
Other Details
Year 2
Amount paid for Year 2
Tax Receipt No for year 2
Location of payment
Other Details
Year 3
Amount Paid for Year 3
Tax Receipt No for year 3
Location of Payment
Other Details
Have you ever been in or petitioned for bankruptcy? Give details if yes
Are you a financial contributor to any political or religious or socio-cultural organization? if yes give details
Have you ever had your salaries stopped or any of your properties reposessed	YES NO

Have you had your salaries stopped or any of your properties repossessed	YES NO

Do you have any pending financial judgement against you?	YES NO

Give details on any of the YES answers above
SECTION XX SPACE FOR EXTRA DETAILS
*SECTION XXI: PERSONAL DECLARATION
Have you ever had any security clearance denied, suspended or revoked	YES NO

If ye, state type of clearance and date
Have you ever had any connection with a foreign organization	YES NO

Have you ever been or now an alcoholic	YES NO

Have you ever been dismissed or asked to resign from any position	YES NO

if yes, give details
Are you now or have you ever belonged to a political party or politically-oriented group?	YES NO

If yes, state the political party and level of involvement
List your Hubbies and sporting interests
*SECTION XXII: CERTIFICATION
* I have read and understand the instructions. I certify that the foregoing answers are true to the best of my knowledge and belief.
*I understand that any mis-statement or omission as to material fact will constitute grounds for rejection of my application or for immediate dismissal if already employed
*I also understand that any false statement made herein may be punishable by law
Signature
Date of signature
* SECTION XXIII AUTHORIZATION TO RELEASE INFORMATION
*I hereby authorize any duly accredited representative of the presidency of the federal republic of Nigeria bearing the release, or a copy thereof, within one year of its date,
*to obtain any information from schools,residential management agents, employers, criminal justice agencies, or individuals, relating to any activities.
*This information may include, but is not limited to, academic achievement, performance, attendance, personal history, disciplinary, residential, credit, medical, birth and vital records, criminal and
*I hereby authorize and request your release of such information upon request of the bearer. I understand that the information released
*is for official use only by authorized agencies of the federal republic of Nigeria as necessary in fulfillment of official responsiblities.
*I hereby release any individual, including record custodians, from any and all liability of damages of whatever kind or nature which may at any time result to me on account of compliance,
*or any attempt to comply with this authorization. Should there be any question as to the validity of this release, you may contact me as indicated below
Full name
Signature
Date of signature
Current Address
Telephone number
Parent or Guardian if any