Position Applied for Date filed (MM/DD/YYYY)

PERSONAL DETAILS
List all information in print

Last name (in all CAPS) First name Middle name

Other names (AKA Name) Date of Birth Marital Status

(MM/DD/YYYY)

Date of Marriage Place of Marriage State/City/Province Country

Nationality Gender Personal email address Official email address

National ID no. or Passport no. Country of issue Expiration date

Telephone no. Mobile no. Other no.

PRESENT ADDRESS

Number/Street/Village State/City/Province

Country Postal code

PERMANENT ADDRESS

Number/Street/Village State/City/Province

Country Postal code

PREVIOUS ADDRESSES For the last 10 YEARS

Number/Street/Village State/City/Province Country Postal code Years of stay

From MM/YYYY to
MM/YYYY

Mother's maiden name Father's full name

Spouse' full name

Siblings Birthdate If Employed If studying

 Occupation Company Year/Course School

EDUCATION INFORMATION
List information starting from the highest degree ob tained

Name of Institution

Address State/City/Province Country Postal code

Dates attended (MM/DD/YYYY)

From To

Degree obtained Major

Graduated? □ YES □ NO GPA

Date of graduation (MM/DD/YYYY) Enrollment #

Name of Institution

Address State/City/Province Country Postal code

Dates attended (MM/DD/YYYY)

From To

Degree obtained Major

Graduated? □ YES □ NO GPA

Date of graduation (MM/DD/YYYY) Enrollment #

PROFESSIONAL LICENSES/ CERTIFICATION/ MEMBERSHIP

Li s t information of professional membership starting from the most recent m embership
Name of institution Date joined Type of membership Membership status
(MM/DD/YYYY)
EMPLOYMENT INFORMATION
List information starting from the most recent employer

Name of company Contact number Employee ID

Address State/City/Province Country Postal code

Status of employment Supervisor name Supervisor contact number

□ Permanent □ Contractual □ Probationary

Dates of employment (MM/DD/YYYY)

From To

Can we contact your current employer? □ Yes □ No If No, please provide the date:

Job title Department

Job responsibilities

Reason for leaving Last Salary

Name of company Contact number Employee ID

Address State/City/Province Country Postal code

Status of employment Supervisor name Supervisor contact number

□ Permanent □ Contractual □ Probationary

Dates of employment (MM/DD/YYYY)

From To

Job title Department

Job responsibilities

Reason for leaving Last Salary

Name of company Contact number Employee ID

Address State/City/Province Country Postal code

Status of employment Supervisor name Supervisor contact number

□ Permanent □ Contractual □ Probationary

Dates of employment (MM/DD/YYYY)

From To

Job title Department

 Job responsibilities

Reason for leaving Last Salary

Name of company Contact number Employee ID

Address State/City/Province Country Postal code

Status of employment Supervisor name Supervisor contact number

□ Permanent □ Contractual □ Probationary

Dates of employment (MM/DD/YYYY)

From To

Job title Department

Job responsibilities

Reason for leaving Last Salary

PERSONAL REFERENCES
Name Mobile Number Other Contact Number

Company/ Organization

Position/ Title Relation/ Affiliation

Name Mobile Number Other Contact Number

Company/ Organization

Position/ Title Relation/ Affiliation

Name Mobile Number Other Contact Number

Company/ Organization

Position/ Title Relation/ Affiliation

ADDITIONAL Information

1. Have you ever been arrested or convicted of any criminal offense? Yes No If yes, please provide details
 Isthe case still pending? Yes No

2. Have you ever been declared bankrupt or had a petition of bankruptcy? Yes No If yes, please provide details

3. Have you ever been involved in any civil judgments, as a Plaintiff or Defendant? Yes No If yes, please provide
details

4. Have you ever been refused entry to any country? Yes No If yes, please provide details

5. Have you ever been terminated or dismissed by any employer? Yes No If yes, please provide details

6. Have you ever been involved in any act of violence? Yes No If yes, please provide details

7. Are you currently engaged in any other business either as a propr ietor,
partner, director, trustee, and employee or otherwise?

Yes No

If yes, please provide detail

Declaration

I hereby certify that all information provided in this form is accurate and complete to the best of my
knowledge. I understand that any misrepresentation and/or falsification of any fact may result in
cancellation of employment or immediate dismissal.

I recognize that in connection with employment with _____ , I may be subject to a background enquiry
and hereby authorize the same.

Letter of Authorization

I hereby authorize Vanguard Screening Solutions Inc., to verify information provided in the above form
for Pre-Employment purposes. I authorize all persons who may have information relevant to this
enquiry to disclose it to Vanguard Screening Solutions Inc. and its partners, associates, and release all
persons concerned from liability on account of such disclosure. I hereby voluntarily affix my signature
and represent this document to be an original.

I further authorize the procurement of a consumer credit report or other like documents and
understand the report may contain information on my background, mode of living, character, and
personal reputation.

I further acknowledge, consent and agree that photocopies of this Letter of Authorization may be made
and used as if they were original copies.

Signed : May 12, 2023

Full Name : JAZREEL JADE T. QUEMADO
Date of Birth : 08/10/1995 (DD/MON/YYYY)
Identification : _____________________
Date : May 12, 2023