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 (MM/DD/YYYY) Marital Status

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

Years of stay
Number/Street/Village State/City/Province Country Postal code From MM/YYYY to MM/YYYY

Mother's maiden name Father's full name

Spouse' full name

If Employed If studying
Siblings Birthdate
Occupation Company Year/Course School
 EDUCATION INFORMATION
List information starting from the highest degree obtained
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

List information of professional membership starting from the most recent membership
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

Is the 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 proprietor,

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 : _____________________________
Full Name : _____________________________
Date of Birth : _____________________________ (DD/MON/YYYY)
Identification : _____________________________
Date : _____________________________