Instructions: The applicant must complete this form. All questions must be answered completely and truthfully.

Failure to provide
complete and truthful information may result in the refusal or delay of your application. Please print clearly.

PERSONAL INFORMATION

Last Name Email Address

First Name Landline

Middle Name Mobile Number

Former Name
Alternative Number (if any)
(Maiden Name If Married)
Date of Birth
Social Security System (SSS)
(mm/dd/yyyy)
Gender Tax Identification Number (TIN)

Civil Status Passport ID Number

Contact Person in case of
Contact Number of Emergency
Emergency & Relationship to the
Contact Person
candidate

RESIDENTIAL ADDRESSES (please include current, permanent and previous addresses)

 People Living/Lived with
Period of stay
Complete Addresses  Relationship
(month & year)
 Contact number

1
EDUCATIONAL BACKGROUND

TERTIARY EDUCATIONAL BACKGROUND

Name of the University / College

Address / Location / Campus

Dates of Attendance
(From – To)

Please check the appropriate box Graduate: Undergraduate:

Year Level if Undergraduate:
Date of Graduation

Course Taken

Dean’s Name & Contact Details

SECONDARY EDUCATIONAL BACKGROUND

Name of the High School

Address / Location / Campus

Dates of Attendance
(From – To)

Please check the appropriate box Graduate: Undergraduate:

Year Level if Undergraduate:
Date of Graduation

Teacher’s Name & Contact Details

2
 EMPLOYMENT RECORDS (Start from the most recent)

MOST RECENT EMPLOYER

Company Name
Agency Name
Company Address / Location / Branch

Company’s Contact Number

Position Title

Employee ID Number

Start Date (mm/dd/yyyy)

Separation Date (mm/dd/yyyy)
Please write PRESENT, if currently
connected with the company
Employment Status
(Contractual, Probationary, Regular)
Reason for Leaving

Supervisor’s Name & Contact Details

** Do you grant permission to contact your current employer/ supervisor? (Yes? If No, When?) ______________

EMPLOYMENT 2
Company Name
Agency Name
Company Address / Location / Branch

Company’s Contact Number

Position Title

Employee ID Number

Start Date (mm/dd/yyyy)

Separation Date (mm/dd/yyyy)
Please write PRESENT, if currently
connected with the company
Employment Status
(Contractual, Probationary, Regular)
Reason for Leaving

Supervisor’s Name & Contact Details

3
EMPLOYMENT 3
Company Name
Agency Name
Company Address / Location / Branch

Company’s Contact Number

Position Title

Employee ID Number

Start Date (mm/dd/yyyy)

Separation Date (mm/dd/yyyy)
Please write PRESENT, if currently
connected with the company
Employment Status
(Contractual, Probationary, Regular)
Reason for Leaving

Supervisor’s Name & Contact Details

____ EXPERIENCED PROFESSIONALS - Kindly provide a minimum of three (4) to a maximum of eight (8) names and contact
numbers of former Immediate Supervisors.

NAME RELATION COMPANY CONTACT NUMBER / S

1 HR / IMMEDIATE SUPERIOR

2 HR / IMMEDIATE SUPERIOR

3 HR / IMMEDIATE SUPERIOR

4 HR / IMMEDIATE SUPERIOR

5 Former Colleague

6 Former Colleague

7 Former Colleague

8 Former Colleague

4
 ____ FRESH GRAD/NO WORK EXPERIENCE - Kindly provide a minimum of five (5) names and contact numbers of former On-the-Job
Training Supervisors or College Professors.

NAME RELATION COMPANY CONTACT NUMBER / S

1 COLLEGE PROFESSOR

2 COLLEGE PROFESSOR

3 COLLEGE PROFESSOR

4 OJT SUPERVISORS
OJT SUPERVISORS/
5
COLLEGE PROFESSOR
OJT SUPERVISORS/
6
COLLEGE PROFESSOR

5
 ADDITIONAL INFORMATION

Have you ever been arrested for or convicted of a criminal

offence?
1
If yes, please provide details
Have you ever been declared bankrupt or had a bankruptcy
petition made against you?
2
If yes, please provide details
Have you been involved in any civil judgments, as a Plaintiff or
Defendant?
3
If yes, please provide details
Have you ever been refused entry to any country?
4
If yes, please provide details
Have you ever been suspended or dismissed by an employer?
5
If yes, please provide details
Are you currently engaged in any other business either as a
proprietor, partner director, trustee, employee, and agent or
6 otherwise?

If yes, please provide details

Kindly explain why your Outside Business Interests would or
7
would not result in any form of conflict with your proposed role.

DECLARATION

I declare that all the data that I have provided above are true, valid and complete and I understand that omission or
misrepresentation of any fact may result in refusal of employment or immediate dismissal.

I hereby permit the authorized representative to verify/validate the contents stated herein. I trust that this information shall remain
confidential.

_______________________________
Candidate's Signature
(Over Printed Name)

Date: __________________

6
 CONSENT LETTER in lieu of Data Privacy Act of 2012
Republic Act No. 10173

To whom it may concern,

This is to authorize to release my academic records and/or verify

(School Name)
The authenticity of my school documents in connection with my application for employment.

This is to further authorize the HB6 (Hiring Basix), as the 3rd background checking company of the
company I am applying for, to obtain academic records and/or verify the authenticity of my school
documents from the .
(School Name)

Finally, this is to waive the privacy of academic records and hold ,

(School Name)
its Registrar and school officials, free from any liabilities or damages in connection with the release of
academic records and/or verification of the authenticity of my school documents.

––––––––––––––––––––––––––
Signature over printed name

––––––––––––––––––––––––––
Date

7
 CONSENT LETTER in lieu of Data Privacy Act of 2012
Republic Act No. 10173

I hereby grant authorization the employer and any person or organization acting on its behalf to verify information presented in my
application form and to procure a background screening report for that purpose. I understand that such a report may contain
information about my background, character and personal reputation. I further understand and agree that, in the event of my
employment, a background screening report may be procured in connection with subsequent employment decisions.

Upon my written request, I will be advised of the name and address of each employment reporting agency from which an
employment report or investigative report may have been obtained. I also voluntarily authorize HIRING BASIX, vendor of the
employer on its behalf, to perform reference checks of my employment (with the exception of my current employer, unless I have
authorized such contact or commenced employment with Employer) and such other checks and inquiries are necessary in order
to verify information provided by me in my employment application. I hereby release from liability all persons or entities requesting
or supplying such information. Moreover, I understand that my employment with the Firm may be terminated with immediate effect
should any information provided herein be proven untrue.

Full Name: _____________________________

Date of Birth: _____________________________

Identity #: _____________________________
(Valid ID)

Date: _____________________________

Signature: _____________________________