Nursing Fellowship Application form 2008

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1 Nursing Fellowship Application form 2008 Management Sciences for Health, Abuja Please read the Notes for Applicants before completing all sections of this form in typescript or black ink. Only Nigerian citizens are eligible to apply. A note at the end of this form explains who will see the information you supply to us, and why. Part A Personal details Family name Other name(s) Title Mr Mrs Miss Ms Dr Gender Male Female Place of birth Date of birth Status Single Married Divorced Widowed State of origin Your address; where we should send letters Name, address of next of kin person who should be contacted in the event of an emergency (please state relationship). Mobile number Mobile number Please tick this box to confirm that you have told your emergency contact that you have given us their details. Where are you currently working?

2 Please provide details of your post, grade and main responsibilities. Contact details of line manager or supervisor Name of your line manager Position Department Organisation Address Fax 2 NF/001/2008

3 Part B Academic background Please list all academic qualifications gained since completing your secondary education, stating the institutions attended, the main subjects of study, and when the main courses started and finished. Qualification Institution Subject From To Part C Employment History Please list all positions held since completing your secondary or tertiary education. Position Organisation/institution From To 3 NF/001/2008

4 Part D Referees Please attach letters from two (2) referees (both of whom should be professional or academic) in support of your application for a Nursing Fellowship. Please provide details of the two referees below. If you are unable to attach letters from your referees, please ask them to write to us as soon as possible. First referee Title and name Position Fax How long have you known this referee? What is his/her professional relationship to you? Second referee Title and name Position Fax How long have you known this referee? What is his/her professional relationship to you? Please tick this box to confirm that you have informed your referees that you have given us their contact details. 4 NF/001/2008

5 Part E Statements about yourself and your plans Personal statement What are your reasons for wanting to be part of the Nursing Fellowship Program? Explain how it will help your career and personal development on your return to your organisation/hospital/clinic or community. Try to do this in no more than 500 words. Also explain what benefits it will bring to your organisation/hospital/clinic or community. Be brief we can explore the detail at interview if necessary. Your plans for the future Please provide an outline of your ambitions and career plan. How do you intend to make a difference in your organisation/hospital/clinic or community? Try to do this in no more than 250 words. We can discuss your plans at interview. 5 NF/001/2008

6 Are you a potential leader? Nursing Fellowship is unique in that it looks for future leaders, who can use their influence and standing to bring benefits to their organisations and communities. Describe your most outstanding non-academic achievement where you demonstrated leadership potential. It should involve other people, and it may be an extra-curricular/sport/community/professional activity or an assignment. Try to do this in no more than 250 words. We can discuss it further at interview. 6 NF/001/2008

7 Part F Medical Records DISABILITIES * People with disabilities means people who have a long term or recurring physical or mental impairment which substantially limits their prospects of entry into or advancement in employment or the performance of normal day to day tasks or functions. Are you Disabled? (yes / no) If Yes, please state the kind of disability. MEDICAL INFORMATION (please attach medical report from a Government funded hospital) Do you have any medical history or condition that may affect your ability to meet the requirements of the specific position that you are interested in applying for? (If yes, please specify.) 7 NF/001/2008

8 Data Protection Thank you for providing us with information about yourself on this form. We will look after the information carefully and use it to consider your suitability for a Nursing Fellowship Program and to manage the application process. It will be made available to staff at the Management Sciences for Health and to her implementing partner organisations. It may also be made available for the same reasons to the funders of the Fellowship, and to members of any panel that interviews you. Should a need arise for us to use your information in any way, we may have to ask for your permission. If you are unsuccessful, the information will be held securely and destroyed in due course. In signing this application form for a Nursing Fellowship you accept that you will be bound by these conditions. You also accept that we will use the information you have given us in the ways we have described. Signature Date Completed application form should be sent to the following address by 08 February For official use only Other documents attached to this form (please tick): Resume One passport photograph Letters from two referees Declaration of Health 8 NF/001/2008

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