CI For New Applicant

SUMULONG COLLEGE OF ARTS AND SCIENCES
Background Investigation
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 do a background screening
report for that purpose. I further understand and agree that, in the event of my employment, a
background screening report may be done in connection with subsequent employment
decisions.
Upon my written request, I will be advised of the name and address of each employment
report or investigative report may have been obtained. I also voluntarily authorize Sumulong
College of Arts and Sciences, to perform reference checks of my employment (with the
exception of my past employer, unless I have authorized such contact or commended
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 #: _________________________
Date: ____________________________
Signature: ________________________
______________________________________________________________________
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 Civil Status
First Name Email Address
Middle Name Landline
Maiden Name/ Former Mobile Number

Name (If applicable)
Date of Birth Alternative
Number (if any)
Tax Identification Number Social Security
(TIN) System (SSS)
Contact Person in case of Contact Number
Emergency
Current Address
___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.
___EXPERIENCED PROFESSIONALS- Kindly provide a minimum of three (3) to a maximum of eight

(8) names and contact numbers of former immediate Supervisors.
PROFESSIONAL/ EMPLOYMENT REFERENCES
FOR FRESH GRAD/ NO WORK EXPERIENCE (minimum of 4)
NAME RELATION SCHOOL/COMPANY CONTACT NUMBER/S

EXPERIENCED PROFESSIONALS (minimum of 5)
NAME RELATION SCHOOL/ COMPANY CONTACT NUMBER/S
CHARACTER REFERENCES (Neighbors, Barangay Officials and Colleagues from different

organizations)
NAME RELATION SCHOOL/ COMPANY CONTACT NUMBER/S
RESIDENTIAL ADDRESSES (please include current, permanent and previous addresses)
Complete Addresses Period of stay People living/lived with, relationship

(month & year) and contact number
EDUCATIONAL BACKGROUND
University Address/Location Dates of Date Qualification

Attendance Graduated (Course)
EMPLOYMENT BACKGROUND (Start from the most recent)
Company Name/ Complete Position Title Dates of Contact No (s) Reason

Agency Name Address and Employee Employment for
(STRICTLY ID Number (Month/Day/Year) Leaving
include)
1. Do you grant permission to contact your current employer/ supervisor?

(Yes or No)____________
2. Please account for any employment gaps of more than 1 month (if any) _________
ADDITONAL INFORMATION
1 Have you ever been arrested for or

convicted of a criminal offense?
2 If yes, please provide details
3 Have you ever been declared
bankrupt or had a bankruptcy
petition made against you?
4 If yes, please provide details.
5 Have you been involved in any civil
judgments, as a Plaintiff or
Defendant?
7 Have you ever been refused entry
to any country?
9 Have you ever been suspended or
dismissed by an employer?
0
1 Are you currently engaged in any
1 other business either as a
proprietor, partner director, trustee,
employee, and agent or otherwise?
2
1 Kindly explain why your Outside
3 Business Interest would or would
not result in any form and 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: _________________
LETTER OF AUTHORIZATION
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 do a background screening report for that
purpose. I understand that such a report may contain information about my backgrounds, character
and personal reputation. I further understand and agree that, in the event of my employment, a
background screening report may be done in connection with subsequent employment decisions.
Upon my written request, I voluntarily authorized Sumulong College of Arts and Sciences, to perform
reference checks of my employment (with the exception of my past 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 #: _________________________
Date: ____________________________
Signature: ________________________

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SUMULONG COLLEGE OF ARTS AND SCIENCES

CONSENT LETTER in lieu of Data Privacy Act of 2012

Full Name: ________________________

Date of Birth: ______________________

Last Name Civil Status

First Name Email Address

Middle Name Landline

Maiden Name/ Former Mobile Number

___EXPERIENCED PROFESSIONALS- Kindly provide a minimum of three (3) to a maximum of eight

PROFESSIONAL/ EMPLOYMENT REFERENCES

FOR FRESH GRAD/ NO WORK EXPERIENCE (minimum of 4)

NAME RELATION SCHOOL/COMPANY CONTACT NUMBER/S

NAME RELATION SCHOOL/ COMPANY CONTACT NUMBER/S

CHARACTER REFERENCES (Neighbors, Barangay Officials and Colleagues from different

NAME RELATION SCHOOL/ COMPANY CONTACT NUMBER/S

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

Complete Addresses Period of stay People living/lived with, relationship

University Address/Location Dates of Date Qualification

EMPLOYMENT BACKGROUND (Start from the most recent)

Company Name/ Complete Position Title Dates of Contact No (s) Reason

1. Do you grant permission to contact your current employer/ supervisor?

1 Have you ever been arrested for or

Full Name: ________________________

Date of Birth: ______________________

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