Access Request Form

Note: Any person , including an employee who is not an Authorized Personnel but wishes to access
Personal Data of Data Subjects pursuant to his/her junction in the Company, shall accomplish thisAccess
Request Form. Verbal requestfor access shall not be allowed. TheAccess Request Form may befiled with
the Authorized Personnel who has custody of the Personal Data to be accessed. The Authorized
Personnel may either approve or reject the same, depending on the merits of the reasons provided for the
requested access. In no case shall access be approved if no meritorious reason is provided in the
Access Request Form. If approved, the Authorized Personnel shall endorse for final approval the
Access Request Form to the Data Protection Officer (DPO). Once approved, the Access Request
Form shall be transmitted to the branch, sub­ office, component unit, or department concerned for
implementation

REQUESTOR INFORMATION

Name:

Company Position if any:

Email

Contact Number:

Purpose of Request:

As proof of my capacity 🮱 Birth certificate, to prove filiation

to access the Personal Data, 🮱 Court Order
I hereby enclose: 🮱 Written Authorization from Data Subject
🮱 Others, please specify _____________________________________

REQUESTED PERSONAL DATA

To whom Personal Data

pertains to (i.e., name of Data
Subiect):

Description of the
Requested Personal
Data:

Date or period around which

Personal Data was collected,
if known:

Name of the
Department or Company
Employee which/who
processed the Personal Data,
if known:
NATURE OF REQUEST

I hereby request you to:

🮱Inform me whether you hold the Requested Personal Data

🮱Supply me a copy of the Requested Personal Data that_you hold
🮱All of the above

Preferred Manner of Addressing the Request

I would prefer that you:

🮱Send me a paper-based/physical copy of the Requested Personal Data through the following address:
🮱E-mail me an electronic copy of the Requested Personal Data through the following:
🮱Others, please specify:

SIGNATURE

I hereby attest that all information stated in this form are true and correct to the best of my knowledge. I
understand that any concealment, false statement, and/or non-declaration shall constitute fraud, which
shall be a ground to file legal action against me, and I waive my
rights to institute any case arising from this situation.

I have provided the information herein after having been informed of the purpose for its processing, and
I expressly give my consent therefor. I understand that it is my choice as to what information I provide
and that withholding or falsifying information may act against the best interests of my relationship with
the Company. I am aware that I can access my personal information on request, and if necessary,
correct information that I believe to be inaccurate. I understand that if, in exceptional circumstances,
access is denied for legitimate purposes, I will be informed of the cause thereof and the remedies for
the same.

Furthermore, I warrant that I have: (i) obtained consent from third persons, if any, to disclose their
information included in this form; and (ii) informed said third persons of the purpose for the disclosure
and collection of information. I will indemnify and hold the Company free and harmless from any and all
claims arising from the breach of this warranty, for damages, and for actual legal fees to defend such
claims, if any.

This consent for the Company to use or process the information herein shall be valid for the duration of
my relationship and/or contract with the Company and for thirty (30) years thereafter, to comply with
statutory and governmental rules and regulations.

SIGNATURE OVER
PRINTED NAME