ࡱ> Y )bjbj[[ J\9 \9 \ 68 bb8dbl,"y,{,{,{,{,{,{,$/1,6|,bbF,db8y,y,V%@&Tl%zm %& e,,0,1&x^2"^2&^2&,,,^2 > (:   INSTITUTE OF CHARTERED SECRETARIES AND ADMINISTRATORS OF NIGERIA APPLICATION FORM FOR INTERNSHIP TitleLast Name (Surname)First nameMiddle name   This form is aimed at obtaining important information from you in order to consider you for the Internship programme of the Institute. PERSONAL DATA Date of Birth (dd/mm/yyyy):_____________________________________________________ Gender: ____________________________________________________________________ Nationality: __________________________________________________________________ State of Origin: _______________________________________________________________ Home Town Address:------------------------------------------------------------------------------------------------- RESIDENTIAL ADDRESS & CONTACT DETAILS House No: _______ Street Name: ______________________________________________ Postal Address:________________________ City: ________________________________ Telephone: __________________________Mobile: ________________________________ Telephone (Home): _____________________ Email: _______________________________ MARITAL STATUS  Single  Married DETAILS OF SPOUSE (applicable only if married) Name: ________________________________________________________________ Occupation: ____________________________________________________________ Name of employer: ______________________________________________________ Office address: _________________________________________________________ Telephone number: ________________ Mobile:________________________________ Email address:__________________________________________________________ EDUCATION (Start from the most recent) EDUCATION 1 Name of Institution: _________________________________________________________ Course Studied: ____________________ Area of Specialization: _____________________ Year of Commencement: _________________ Year of Completion: ___________________ Country: _____________________________ (State): ______________________________ Qualification: ______________________________________________________________ EDUCATION 2 Name of Institution: _________________________________________________________ Course Studied: ____________________ Area of Specialization: _____________________ Year of Commencement: _________________ Year of Completion: ___________________ Country: _____________________ (State) :______________________________________ Qualification: _______________________________________________________________ PROFESSIONAL QUALIFICATION 1 Name of Institution: _________________________________________________________ Course Studied: ____________________ Area of Specialization: _____________________ Year of Commencement: _________________ Year of Completion: ___________________ Country: _____________________ (State): _______________________________________ Qualification: _______________________________________________________________ PROFESSIONAL QUALIFICATION 2 Name of Institution: _________________________________________________________ Course Studied: ____________________ Area of Specialization: _____________________ Year of Commencement: _________________ Year of Completion: ___________________ Country: _____________________ (State): _______________________________________ Qualification: _______________________________________________________________ PREVIOUS EMPLOYMENT HISTORY (i) Name of Employer:__________________________________________________________ Location (State): ____________________________________________________________ Address:________________________________________Phone Number:_____________ Location: __________________ From: (___________) to _____________________ to date Job Title: _________________________________________________________________ (ii) PREVIOUS EMPLOYER Name of Employer:__________________________________________________________ Location (State): ____________________________________________________________ Address:__________________________________________Phone Number:____________ From: _________________ To: ________________________________ ____________ Job Title: _________________________________________________________________ NEXT OF KIN Name: ___________________________________________________________________ Relationship: ______________________________________________________________ Address: _________________________________________________________________ Telephone number: ________________________________________________________ Email address:____________________________________________________________ CONTACT IN CASE OF EMERGENCY Name: __________________________________________________________________ Relationship: ______________________________________________________________ Address: _________________________________________________________________ Telephone numbers: ________________________________________________________ DETAILS OF INTEREST (Sports, Hobbies, etc.)  HAVE YOU EVER BEEN DISMISSED BY YOUR PREVIOUS EMPLOYER OR YOUR APPOINTMENT TERMINATED AS A RESULT OF MISCONDUCT OR FINANCIALLY INDEBTED TO ANY PREVIOUS EMPLOYER? IF YES, GIVE DETAILS: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ __________________________________________________________________________ REFERENCES REFEREE 1 Name: ____________________________________________________________________ Position: __________________________________________________________________ Office Address: _____________________________________________________________ Telephone number: _________________________________________________________ Email Address: _____________________________________________________________ REFEREE 2 Name: ____________________________________________________________________ Position: __________________________________________________________________ Office Address: _____________________________________________________________ Telephone number: __________________________________________________________ Email Address: _____________________________________________________________ DECLARATION In furtherance of my application for the Internship programme of the Institute, I hereby declare that the information given above is correct. Signature of applicant______________________________ Date ______________________ PARTICULARS OF SPONSORS (WHO MUST BE ICSAN MEMBERS) AND SIGNATURE: - Name: _____________________________ Signature:__________________________________ Address: _______________________________________________________________________ Grade of ICSAN Membership and Number:_____________________________________________ Name: _____________________________ Signature:__________________________________ Address: _______________________________________________________________________ Grade of ICSAN Membership and Number:_____________________________________________ FOR OFFICIAL USE ONLY COMMENTS BY THE SECRETARIAT Are required documents attached to the application?: ___________________________ Is the applicant qualified to participate in the programme?:___________________________ What are the reasons for your recommendation?: ___________________________ _________________________ _______________________ _____________ _____ Name Designation Signature Date RECOMMENDATION OF THE CORPORATE MEMBERS COMMITTEE We hereby recommend the applicant for the approval of the Council _________________________ _______________________ _____________ _____ Name Designation Signature Date APPROVAL OF THE COUNCIL The recommendation is approved by the Council and signed on its behalf by: _________________________ _______________________ _____________ _____ Name Designation Signature Date     PAGE  PAGE - 6 - Please affix a white background passport photograph.  12LTlmn. / 0 1 ǵ{m_[W[PLHLA: h45\ h4h4hJh4 h5\hmhhnh5B*\phhOGhkt5CJ \aJ hJ5CJ,\aJ,h0|whJ5CJ,\aJ,hJ5B*CJ(\aJ(ph#hJhJ5B*CJ(\aJ(ph#hJhJ5B*CJ\aJph8jhJhJ5B*CJUaJmHnHphtH u h95\(jhBBI5CJZU\aJZmHnHu 2Lmnt $Ifgd*AgdPgdJ $da$gdJ-$$$ $Ifgd*AkdQ$$Ifl\ZH<'   t(0\(644 lap(ytn?=kdR$$Ifl\ZH<'  t0\(644 lap(ytn $Ifgd*A0 1 ? @ 1 2  o p   _ ` o q y ~ gd}$a$gdg`1 > ? @ H s  0 2 @  ) = > ~ ! = > ^ _ ` n o ɽͽ͹ͯh'hw=5\h'h'5\ hph}hm h}h}h}5\hJ&hPhCOhiGhq)hk4h\+ hG`\ hk4\ h>R\h>RhUhU5\ h>R5\ hU5\3o p y z      O P Q R b c d *123|}~¸ִ괬ꬨꨬꔐhx+ht5>*\hx+h0[hEDrh}hJhmnh hJ&hm h; h}hEDr5\h}h-A5\h}hk45\h}h&W5\h}hJ&5\hk4hw=jh}UmHnHu2~   Q R 23|}~XYgdWXgd:gd gd; gdw=)+@AWYmn"+8AGHISTWXklĴȬȨȨȨȨȴיוȕh h5\hJh}h-h@h#?hhWXh:hbBhp~hm h } hw=5\ h}5\ h#=|5\ h:5\hx+h:&5>*\h:5>*\:YHIWXLM ]^gdgdJgdgd-gdWX$67GKMTUtu   !"lm  )*@IRabo|!"NOg$5>KWX h2\hJ h}5\ hJ5\hJh&h}h-hhm hNSTfg XYuvzbcgdWgd%^gd&gd4BgdgdJXYtuvyz+GSTU]^ackl ".UVjʾʺʾʺʲʮમΦʲٟʊhECh|h|hW5\ hP5\ h|5\h@h@h4Bh%^h}hxChPh!YhMh&h hkt5\ h@5\hWhVk5>*\hEChPr5>*\hJ5>*\4 ijWXJKLMgdGgdxCgd|gdWjrz{   %()?HIVWXab  ;IRS>KLMQmnopʦh!h!h&5\ hJ5\ h!5\h%+hhv hkt5\ hv5\h0DhGhVkh@hPh}hxCh&h|hEC@MNOPQopqr?@gdgdkgd7gdF1gdgd!bp')/0d|?ü鵮鼧霘vhrh o5>*\hrh7N5>*\hJ5>*\hJhhk h o5\ h 8,5\ h@5\ hk5\ hJ5\hF1 jh5U\mHnHuhDTh5\ h5\ h&5\h 8,h}h!h&-89"#pq{|  d e !gd7NgdbM1gd7gdk/789AB}!01goq{|  $ % [ c u v !!!!9!^!a!!!!!!!!!!!!ļȴh2hB_~h6\h@hv hhhk4hA hA5\hmnh7Nh7Nhmn5\hbM1hhh 8,h&hF` h7N5\B!!!!!!!!!!!9"""7###6$P$l$m$$gdv dhgdmn dhgdr hdh^hgdmn & Fdhgdmn dhgdgdL@gd7!!!!("9"]"^""""""""""##Ŵ~jWC//~'hrhrOJPJQJ\^JnH tH 'hrhOJPJQJ\^JnH tH $h5OJPJQJ\^JnH tH 'hrhmnOJPJQJ\^JnH tH !hmnOJPJQJ\^JnH tH !hOJPJQJ\^JnH tH 'hhOJPJQJ\^JnH tH !hrOJPJQJ\^JnH tH *hh5OJPJQJ\^JnH tH $hr5OJPJQJ\^JnH tH  h 8,5\ hv5\hv ##6#7#[#\########$$$7$:$P$X$[$k$m$?&U&g&p&r&{&&ڵڤ}ڤvoh^vY^o^vQYhvhv\ hv\hvhv5\ h35\ h 8,5\ hv5\$hr5OJPJQJ\^JnH tH 'hrhmnOJPJQJ\^JnH tH !hmnOJPJQJ\^JnH tH 'hhrOJPJQJ\^JnH tH !hOJPJQJ\^JnH tH !hrOJPJQJ\^JnH tH 'hrhrOJPJQJ\^JnH tH $$%%v%w%%>&?&q&r&&&&''''''''7(((((((gd3gdv&'''''''((((((((((((((((((((((((()))Ǯёh1'hg`hg`5CJ\aJhg`5CJ\aJh}Q0JmHnHuhgrhko hko0Jjhko0JUh3)#jh3)#U h0h\hvh35\ h35\ h 8,5\ h3\#((((((((((((())))gdv$a$gd1'  !D%gdy#  &`#$gdgrH 0090P1h0:py# . 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