La Concepcion De La Autoridad

|FAO |IAEA |ILO |ITC |
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|I hereby authorize any of the doctors, hospitals orclinics mentioned in this form to provide the United Nations Medical Service with copies of all my medical records |
|so that the Organization can take action upon my application for employment. |
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|I certify that the statements made by me in answer to the questions below are, to the best of my knowledge, true, complete and correct. I realize that any incorrect |
|statement or material omission in the medical information form or in any other document required by the Organization renders a staff member liable to termination or ||dismissal. |
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| Date:(dd/mm/yy)dd |     |Signature: | | |
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|Pages 1 and 2 are to be completed by the candidate |
|FAMILY NAME (IN BLOCK CAPITALS) |GIVEN NAMES |MAIDEN NAME (FOR WOMEN ONLY) |SEX ||      |      |      | M F |
|ADDRESS (STREET, TOWN, DISTRICT OR PROVINCE, COUNTRY) |DATE OF BIRTH |
|     |      |
| |NATIONALITY |
| |     |
|POSITION APPLIED FOR (DESCRIBE NATURE OF WORK) |TELEPHONE |BIRTHPLACE |
|      |      |      |
||PRESENT MARITAL STATUS |
| | |Single |
| |...