Kingdom of Saudi Arabia

Ministry of Higher Education

King Saud University

Photo

Medical City
Human Resources

Employment Application Form

(Page 1 of 4)
Reference No.

Date of
Application:

Position Applying
For:

Part I: Personal Information:

Name:
Gender:

Male

Female

Date Of

Marital

Birth:

Status:
Saudi ID /
Passport #
Iqama#
E-Mail

Nationality

Religion:

Mobile

Land Line

No.
No.
Have you previously been employed at KSA?

No.

Married
Single

Address
Yes

Pl. specify the city and organization name:

Location of nearest Saudi Arabian Embassy (If Applicable)

Have you ever been convicted of any crime, felony, or misdemeanor?
No.

Yes, (Pl. specify):

....
Has your registration/license ever been suspended or cancelled due to a professional practice issue?

No

Yes, (Pl. specify):

Part II: Summary of Qualification:

College/
University

Degree
conferred

Total Years
of Study

Graduation
Date

Name of School/
University

GPA

City/
Count
ry

Highest graduate
study
Post graduate
Study
Specialized
Training

Comments:
.

Part III: Professional registrations

Professional
Licensing Body

Specialty

License/Registratio
n No.

Date of Expiration

City/
Count
ry

Comments:
.

P.O. Box: 7802, Riyadh 11472 Tel: 469-2851 Fax: 467-9766 467-9766 : 469-2851: 11472 7805 ..

Kingdom of Saudi Arabia

Ministry of Higher Education

King Saud University

Medical City
Human Resources

Part IV: Summary of

Employment:
(Pl. start from recent employer)

Starting
Date

Last Position
Held /
Job Title

Ending
date

City/
Countr
y

Ward / Unit /
Department

Employer name

(Page 2 of 4)

Part V: References To Be Contacted

Name

Position

Address

Mobile

Email

1
2
3

Part VI: Name Of Relatives Working at KSU-MC (if any)

Name

Position Title

Department

Location/
Hospital Name

Relationship

1
2
3
4

Part VII: EMERGENCY CONTACT DETAILS:

In order to speed up our recruitment process, please give details of an alternative contact person
(name, telephone, fax and e-mail):
Persona to be contacted:
Relationship:

Telephone

Email:

Cell Phone:

Part VIII: Authorization

I affirm the information given above is true and correct. I understand that false or misleading information may
result in my termination of employment from King Saud University Medical City.
I also authorize KSUMC to make inquiries and consult with all persons, places of employment, education,
malpractice carriers, state licensing boards, or other similar government and non- government entities who may
have information bearing on my moral, ethical and professional qualifications and competence to carry out the
privileges I have requested.

Signature of

Date:

applicant:

THANK YOU
P.O. Box: 7802, Riyadh 11472 Tel: 469-2851 Fax: 467-9766 467-9766 : 469-2851: 11472 7805 ..

Kingdom of Saudi Arabia

Ministry of Higher Education

King Saud University

Medical City
Human Resources

(Page 3 of 4)

MEDICAL HISTORY
Date of
Birth:
Height:
Weight:
Blood
Group:
BMI:

(Body mass index)

Please check the appropriate column if you have or have had the following complaint or symptoms or if you have
been advised to seek treatment of the following: (please explain all YES answers by number on the next page
and list specific dates, treatment [if any], and present status).

YES

NO

YES

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Frequent Headaches / Migraine

Difficulty seeing
Glaucoma
Difficulty hearing
Chest pain
Shortness of breath
Palpitations
High blood pressure
Heart attack
Cough
Wheezing in chest / Asthma
Spitting of blood
Night sweats
Tuberculosis
Frequent respiratory infections

38
39
40
41
42
43
44
45
46

Multiple sclerosis
Stroke
Insomnia
Tension inability to relax
Psychiatric treatment
Skin rash
Tumor or cancer
Disability payments
Varicella

47
48
49

16

Peptic ulcer

50

COMPLAINTS OR SYMPTOMS
(for females only)
Menstrual irregularities
Menstrual pains
Lumps in breast
Do you believe you may currently be
pregnant?

17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Gall bladder disease

Constipation
Frequent Diarrhea
Blood in stools
Urinary infections
Blood in urine
Kidney stones
Prostate problems
Hernia
Diabetes
Thyroid disease
Loss of weight
Excessive fatigue
Anemia
Backache

51
52
53
54
55
56
57
58
59

60

NO

IMMUNIZATION
BCG
Tetanus
Diphtheria
Polio
Mumps, Measles, Rubella
Chicken Pox
Influenza
Meningitis
Hepatitis B Series # 1
#2
#3
Have you ever had a Tuberculin skin test?
If Yes give date:

P.O. Box: 7802, Riyadh 11472 Tel: 469-2851 Fax: 467-9766 467-9766 : 469-2851: 11472 7805 ..

Kingdom of Saudi Arabia

Ministry of Higher Education

King Saud University

Medical City
Human Resources
Result:

32

Slipped disc

33
34
35
36
37

Painful or stiff joints

Seizures / Convulsions
Dizziness or fainting
Muscular weakness / paralysis
Polio

Positive

Negative
61

What medicine do you take either regularly or occasionally?

Other Immunization:

62
Allergies:
63
Past hospitalization/ Surgeries:
Have you ever been refused employment insurance or military service for
health reasons?
Yes: _____
No: _____

Average daily consumption:

DATE:
Tobacco:

Alcohol:

SIGNATURE:

(Page 3 of 4)

EXPLANATION OF QUESTION 63 (Past hospitalization/ Surgeries)

DATE

REASON

SURGERY PERFORMED
YES
NO

RESULT OF TREATMENT OR SURGERY

EXPLANATION OF YES ANSWERS FROM QUESTIONS 1 TO 62

NUMBER

EXPLANATION

P.O. Box: 7802, Riyadh 11472 Tel: 469-2851 Fax: 467-9766 467-9766 : 469-2851: 11472 7805 ..

Kingdom of Saudi Arabia

Ministry of Higher Education

King Saud University

Medical City
Human Resources

P.O. Box: 7802, Riyadh 11472 Tel: 469-2851 Fax: 467-9766 467-9766 : 469-2851: 11472 7805 ..