Domestireg background/data check form

    Please scan and attach a clear passport picture along with the form.

    PERSONAL INFORMATION

    Name of Applicant First: Middle: Last: Any other known or native name(s): Maiden Name (if applicable) or any change of name: Current Residence Address: Nearest Bus Stop: Length at Residence: Prior Home Address: Telephone Number: Personal Identifiers: Date of Birth: Place of Birth: Height: Weight: Eye Colour: Sex: Any other facial identifiers or bodily description: Marital Status: Provide Country of Citizenship: If Non-Nigerian, Current Status: NIN Number:
    Work Permit Yes Yes
    No No
    Permit Number: Provide Number and Expiration Date: State of Origin / Local Government Area: Religion:

    EDUCATION

    (A) Have you attended any schools in the last 7 years?
    Yes Yes
    No No
    (B) Have you received a degree or diploma: Qualification: Provide type of degrees(s)/diploma(s) received and date(s) awarded:

    EMPLOYMENT

    Name of Last Employer / Company: Telephone Number of Last Employer: Address of Last Place of Work: How many years at last job: Position held at last job: Personal Bank / Account Details:

    NEXT OF KIN

    First and Last Name: Telephone Number: Address: Nearest Bus-Stop:

    SPOUSE (IF MARRIED)

    Spouse Name/Address: Spouse Job/Address: Spouse Telephone Number: How many children and their names: Name and Address of Church/Mosque: Church/Mosque Pastor/Leader’s Phone:

    DECLARATION

    MR./MRS./MISS I confirm that the information provided on this form is true to the best of my knowledge. I also understand that any falsehood or misrepresentation of facts herein could lead to disqualification or determination of employment. Signature: Date: ***THE APPLICANT IS REQUESTED TO ATTACH A COPY OF THE NEPA/UTILITY BILL, NATIONAL I.D CARD OR VOTERS CARD, OR DRIVERS LICENCE TO COMPLETE THE FORM. ANY PRIOR WORK ID MAY BE ADDED. (Please do not forget to scan and attach a clear passport picture along with the form.) [ file* passport-picture class:form-control-file]

    GUARANTOR PARTICULARS

    Name/Residential: Nearest Bus-Stop: Occupation/Profession/Job Title: Business Name: Office Address: Nearest Bus-stop: Telephone Number: DECLARATION: I do hereby solemnly and sincerely declare that the information provided above is true and that I have known the applicant for years as (state the relationship) . I confirm that he/she is of good character, fit and proper to be considered for employment. I will be responsible for any loss suffered by Domestireg Company arising from any malpractice committed by the applicant in the course of his/her employment with the company or with any other firm where the guarantee is seconded. In the event of any pecuniary loss committed by the applicant in the course of employment, I voluntarily accept to take responsibility of all the charges and expense incurred in the process of recovery of such loss and/or litigation (if any). Guarantor’s Signature: Date: Guarantor’s Passport Picture: