PERSONAL HISTORY FORM

Family Name / First Names / Maiden Name, if any / Sex
Date of Birth / Place of Birth / Nationality at birth / Current Nationalities
Permanent address / Present address (if different)
Marital status:
If you have any dependents, please fill details below:
Name / Date of birth / Relationship
LANGUAGE KNOWLEDGE
Mother tongue:
Other languages: / READ
Easily/ Not easily / WRITE
Easily/ Not easily / SPEAK
Easily/ Not easily / UNDERSTAND
Easily/ Not easily
EDUCATION HISTORY
University or Equivalent:
Name, Place, Country / Period
Mo/Yr - Mo/Yr / Degree/ Distinction obtained / Main course of study
Schools and other formal training from age 14:
Name, Place, Country / Period
Mo/Yr - Mo/Yr / Degree/ Distinction obtained / Main course of study

PERSONAL HISTORY FORM, Part II

EMPLOYMENT HISTORY
Start with present post, and in reverse order every employment- include a not for each period without employment
CURRENT POST:
FROM- TO (mo/yr-mo/yr): / Exact title of post: / Starting salary per year(indicate net/ gross and currency):
Name of employer: / Type of business: / FINAL salary per year(indicate net/ gross and currency):
Address of employer: / Name of supervisor: / Number and kind of employees supervised by you:
Reason for leaving:
Description of duties:
FROM- TO (mo/yr-mo/yr): / Exact title of post: / Starting salary per year(indicate net/ gross and currency):
Name of employer: / Type of business: / FINAL salary per year(indicate net/ gross and currency):
Address of employer: / Name of supervisor: / Number and kind of employees supervised by you:
Reason for leaving:
Description of duties:
FROM- TO (mo/yr-mo/yr): / Exact title of post: / Starting salary per year(indicate net/ gross and currency):
Name of employer: / Type of business: / FINAL salary per year(indicate net/ gross and currency):
Address of employer: / Name of supervisor: / Number and kind of employees supervised by you:
Reason for leaving:
Description of duties:

PERSONAL HISTORY FORM, Part II- continued

EMPLOYMENT HISTORY
FROM- TO (mo/yr-mo/yr): / Exact title of post: / Starting salary per year(indicate net/ gross and currency):
Name of employer: / Type of business: / FINAL salary per year(indicate net/ gross and currency):
Address of employer: / Name of supervisor: / Number and kind of employees supervised by you:
Reason for leaving:
Description of duties:
FROM- TO (mo/yr-mo/yr): / Exact title of post: / Starting salary per year(indicate net/ gross and currency):
Name of employer: / Type of business: / FINAL salary per year(indicate net/ gross and currency):
Address of employer: / Name of supervisor: / Number and kind of employees supervised by you:
Reason for leaving:
Description of duties:
FROM- TO (mo/yr-mo/yr): / Exact title of post: / Starting salary per year(indicate net/ gross and currency):
Name of employer: / Type of business: / FINAL salary per year(indicate net/ gross and currency):
Address of employer: / Name of supervisor: / Number and kind of employees supervised by you:
Reason for leaving:
Description of duties:

PERSONAL HISTORY FORM, Part III

Have you any objections to our making inquiries of your present employer? (yes/no):
REFERENCES:List 3 persons who are familiar with your character and qualifications (do not name relatives or names of supervisors mentioned under Part II of this form
Full name / Address, email and telephone / Business or occupation
Have you ever been arrested, indicted or summoned into court as a defendant in criminal proceedings, or convicted, fined or imprisoned for the violation of any law? (excluding minor traffic violations) yes/no:
State any other relevant facts, including information regarding any residence outside country of your nationality:
I certify that the statements made by me in answer to the above questions are true, complete and correct to my best knowledge and belief:
Date: Signature:

ECPAT International, Personal History Form (v. 2013)Page 1