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 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
______________, and a vendor 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: _____________________________

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Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.
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: *Sex:
*Middle Name: *E-mail Address:
*Former Name: *Landline:
(Maiden Name):

*Date of Birth: *Mobile Number:

*Alternative Number *SSS Number:
(if any):
*Contact Person in *TIN Number:
Case of Emergency:

*Current Address:

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

Period of stay (month & People Living/Lived with, Permanent/

*Complete Addresses year) relationship and contact Previous
number
1

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Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.

PROFESSIONAL / EMPLOYMENT REFERENCES

____ FRESH GRAD/NO WORK EXPERIENCE - Kindly provide a minimum of five (3) names and contact numbers of former On-the-Job
Training Supervisors or College Professors.
____ EXPERIENCED PROFESSIONALS - Kindly provide a minimum of three (3 names and contact numbers of former Immediate
Supervisors.

*FOR FRESH GRAD/NO WORK EXPERIENCE (minimum of 3) – former On-the-Job Training Supervisors or College Professors.
NAME RELATION SCHOOL / COMPANY CONTACT NUMBER / S
1

*EXPERIENCED PROFESSIONALS (minimum of 3) - former Immediate Supervisors / Department Head

NAME RELATION SCHOOL / COMPANY CONTACT NUMBER / S
1

6.

*CHARACTER REFERENCES (minimum of 3) - Neighbors, Barangay Officials and Colleagues from different organizations

NAME RELATION SCHOOL / COMPANY CONTACT NUMBER / S

1

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Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.

EDUCATIONAL BACKGROUND

EDUCATIONAL BACKGROUND

*University / College:
*Address / Location:
*Dates Attended:
* Graduate Undergraduate

*Date of Graduation:
*Course:

EMPLOYMENT RECORD (Start from the most recent)

MOST RECENT EMPLOYER

*Company Name /
Agency Name:

*Company Address:
*Company HR
Contact Details:
*Position Title &
Employee ID Number:
*Dates of Employment:
(MM/DD/YYYY) to
(MM/DD/YYYY)

*Employment Status:
(Contractual, Probationary,
Regular)

*Reason for Leaving:

*Important:
Do you grant permission to contact your current employer? (Yes? If No, when?)

_____________________________________

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Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.

Employment History
*Company Name /
Agency Name:

*Company Address:
*Company HR
Contact Details:
*Position Title &
Employee ID Number:
*Dates of Employment:
(MM/DD/YYYY) to
(MM/DD/YYYY)

*Employment Status:
(Contractual, Probationary,
Regular)

*Reason for Leaving:

Employment History

*Company Name /
Agency Name:

*Company Address:
*Company HR
Contact Details:
*Position Title &
Employee ID Number:
*Dates of Employment:
(MM/DD/YYYY) to
(MM/DD/YYYY)

*Employment Status:
(Contractual, Probationary,
Regular)

*Reason for Leaving:

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Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.

*ADDITIONAL INFORMATION
1 Have you ever been arrested for or convicted of a criminal offence?

If yes, please provide details

2 Have you ever been declared bankrupt or had a bankruptcy petition
made against you?

If yes, please provide details

3 Have you been involved in any civil judgments, as a Plaintiff or
Defendant?

If yes, please provide details

4 Have you ever been refused entry to any country?

If yes, please provide details

5 Have you ever been suspended or dismissed by an employer?

If yes, please provide details

6 Are you currently engaged in any other business either as a
proprietor, partner director, trustee, employee,
and agent or otherwise?

If yes, please provide details

7 Kindly explain why your Outside Business Interests would or 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: __________________

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Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.