APPLICATION FORM FOR ACADEMIC / TEACHING/CLINICAL / FIELD EDUCATION POSTS

NOTES TO APPLICANTS:

For Office Use

1. This application form should be typed or written in block letters. Please use separate sheets for
details or explanations if necessary. The completed application form in duplicate should be returned
to the Human Resources Office, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong
Kong.
2. All information given in this form will be treated in STRICT CONFIDENCE.
3. The personal data in relation to your application will be used by the University to assess your suitability for
assuming the position you are applying for. It may be provided to departments/offices/centres/units, and/or
any other internal/external bodies, where applicable, as authorised by the University to process the
information for purposes relating to the collection of such information.
4. It is our policy to retain the personal data of unsuccessful applicants for future reference purpose for a
period of not longer than two years. When similar vacancies in the University arise during the period, we
may transfer your application to the departments/offices concerned for consideration of employment.
Thereafter, your application together with all materials you provide will be disposed of.

Ref. No.

Shortlisted

Interviewed

Reference

5. Provision of full and complete information in your application and completion of all items on the
application form is obligatory for selection purposes. Failure to provide these data may affect the
processing and outcome of your application.
6. Under the Personal Data (Privacy) Ordinance, you may request for access to, and/or correction of your
personal data in relation to your application. If you wish to do so, please write to the Director of Human
Resources, Human Resources Office, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong
Kong.

Post applied for: PROFESSOR IN MEDICAL LABORATORY SCIENCE IN HEMA & TRANSFUSION SCIENCE (Post
Specialism (if applicable): HAEMATOLOGY AND TRANSFUSION SCIENCE
Department: HEALTH TECHNOLOGY AND INFORMATICS MEDICAL LABORATORY SCIENCE

I learned of this vacancy from THE INTERNET

I

PERSONAL PARTICULARS

Surname: AXIBAL

Given Name (in full): MAXIMO, JR.

Name in Chinese: N/A

Title: Dr
Passport No.

Hong Kong I.D. Card No.: N/A

Philippines EB3193245

Date of Birth: AUGUST 1, 1958

Tel. No.:

Correspondence Address: 1 C SULATAN ST.

(Office)

MANDALUYONG CITY PHILIPPINES

(Res.) 011 63 25336733

Permanent Address: 1 C SULATAN ST.

(Mobile) 63917- 8400- 261

Fax No.:

MANDALUYONG CITY

E-mail:
axibalmdpath@yahoo.com.ph

II

EDUCATION (in chronological order)

Dates of Attendance
(Month / Year)
From

Institution of Learning

Date of Award
(Month / Year)

Qualification or Degree Obtained

To

1974

1978

Far Eastern University, NRMF, Manila,

PHILIPPINES

BS Medical Technology

1978

1979

1983

Far Eastern University, NRMF, Manila,

PHILIPPINES

Doctor of Medicine

1983

2004

2006

Our Lady of Fatima University,

Valenzuela City, PHILIPPINES

Units in Masters in Educational Management

2006

Masters in Management Major in Health Administration

2011

2010

2011

Philippine Christian University, Manila,

PHILIPPINES

* Please delete whichever not applicable.

HR Form 72A (11/2011)

III PROFESSIONAL QUALIFICATIONS (in chronological order)

Name of Professional Institution

How is it obtained
(e.g. by examination)

Name of Award

Date of Award
(Month / Year)

PHILIPPINE BOARD OF MEDICAL

TECHNOLOGY

REGISTERED MEDICAL
TECHNOLOGIST

TRAINING &
EXAMINATION

1978

PHILIPPINE BOARD OF MEDICINE

DOCTOR OF MEDICINE

1985

PHILIPPINE SOCIETY OF CLINICAL

PATHOLOGIST

FELLOW PHILIPPINE
SOCIETY OF CLINICAL
PATHOLOGY

TRAINING &
EXAMINATION
TRAINING &
EXAMINATION

IV

1995

APPOINTMENTS HELD (in chronological order)

Dates (Month / Year)

From

Appointment Held
(For part-time appointments, please specify)

Name of Organization

To
MEDICARE

Medicare Officer I

1990

Quirino Memorial Medical Center, Department of Pathology

Resident Physician

1993

Far Eastern University, NRMF, Department of Pathology

Fatima Medical Center, Department of Pathology

Instructor B
Assistant Professor C
Instructor B
Assistant Professor C
Consultant Pathologist

Friendly Hills Medical Services Inc.

Laboratory Director

Quirino Memorial Medical Center, Department of Pathology

Medical Specialist II

Present

Quirino Memorial Medical Center, Department of Pathology

Medical Specialist III

2011

Present

Armed Forces of the Philippines, V. Luna Medical Center

Department of Pathology

Clinical Pathologist

1995

Present

ACTS Review Center and BRAINS Review Center

Review Lecturer (Board Review Series For Medicine &

Medical Technology/ ASCP/ AMT/ HAAD)

1986

1986

1986
1990
1993

2001

1990

1993

1993

2007

1997

2007

2005

2009

1996

2011

2011

Our Lady of Fatima University, Department of Pathology

FURTHER DETAILS ON PRESENT/MOST RECENT EMPLOYMENT

*Length of notice of resignation to my present employer / If appointed, earliest date available: ONE (1) MONTH / IMMEDIATELY
*Present salary / Last salary: HK$ 45, 000.00 per month ( 12 months per year) / HK$ 40, 000.00 PER MONTH
Date of last salary revision: YEAR 2013
Other allowances (please specify nature of each allowance and amount): NONE
Expected salary: HK$ 45, 000.00 per month (negotiable depending on other privileges offered)
*Former PolyU staff / Serving PolyU staff: N/A

VI

Staff no.: N/A

REFEREES

Please nominate three referees who are able to comment on your suitability for the post applied.
Name
Dr. Remedios A. Magkasi, MD, FPSP,
MHPEd

Ms. Milba M. Rutaquio

Position Held and Organization/

Your Relationship with the Referee

Contact Address, Tel. No., Fax No. and E-mail

Professor III Department of Pathology Far Eastern

46 J Legaspi, Zamora, Meycauyan City, Philippines
University Dr. Nicanor Reyes Medical Foundation, Quezon
CP# 63 923 311 7640; Residence: 011 63 447207895
City, Philippines / Mentor in Laboratory Medicine
Rm. 509 J &T Building 3894
General Manager, ACTS Review Center / one of my
Ramon Magsaysay Blvd
employers in a review center for Medical Laboratory
Sta Mesa, Manila, Philippines 1016
Scientists ASCP, AMT, HAAD
CP#: 63 920 901 8844; Office: 011 63 27167683
Email: info@actsreviewcenter.com

Brigadier Generall (AFP) Joselito P.

Avancena, MD

VII

Surgeon General Armed Forces of the Philippines / one of

my former employer at the Armed Forces of the
Philippines Medical Center

Office of the Surgeon General Armed Forces of the Philippines

2nd Flr Bulwagang Valdez, GHQ, Camp Aguinaldo
Quezon City, Philippines
CP#: 63 917 586 2210 Office: 011 6325023119
Email: navydoc 22@yahoo.com

DECLARATION

1. I declare that the information given above is correct and complete to the best of my knowledge and belief. I understand that if I give any
false information or withhold any relevant information, I shall render myself liable to dismissal upon appointment to the service of The
Hong Kong Polytechnic University.
2. In connection with my application for the post of PROFESSOR, I hereby authorize The Hong Kong Polytechnic University to send my CV
and/or any materials relevant to my application to the referees nominated above for seeking references and any internal/external assessors to be
appointed by the University as deemed necessary. I also authorise the nominated referees to release any relevant information of me to the
University.
3. I understand that upon completion of this recruitment exercise, The Hong Kong Polytechnic University will retain my application for up to
two years even if this application is unsuccessful and I agree to this. I understand that if I do, I should keep the University informed of any
change in my personal particulars after submission of this application form.

Signature:
Name: MAXIMO B. AXIBAL, JR.

*Please delete whichever not applicable.

Date: NOVEMBER 26, 2013