GENERAL EVALUATION FORM

Recruitment Department Form 002 General Evaluation Form (Front)

Revised February 10, 2022

All rights reserved, no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of IPAMS Recruitment Team 1

APPLICANT SIGNATURE

SIGNATURE OVER PRINTED NAME

DATE SIGNED

(mm-dd-yy)

PERSONAL INFORMATION (APPLICANT PROFILE)

Data Privacy Consent:

I, have read this form and understand its contents and voluntarily give my consent for the collection, use, processing, storage, and retention of my personal data or information. I fully understand that the information provided are solely for recruitment by IPAMS which will be shared to the Principal for possible employment. This Data Privacy Consent is made for the purpose of collection and disclosure of my relevant personal information and sensitive personal information to be utilized for processing my application, for documentation, research if applicable, and facilitation of future related transaction. In compliance with Data Privacy Act (DPA) of 2012 and its Implementing Rules and Regulations (IRR) effective since September 8, 2016, I allow and authorize IPAMS to continue to use, retain my information for a period of six (6) months and agree that my information will be deleted/destroyed after this period. I also understand that my consent does not prevent the existence of other criteria for lawful processing of personal data in relation to IPAMS’ operation. I also allow IPAMS to share my information to third parties which are necessary for any of IPAMS’ legitimate business purpose with IPAMS’ assurance that security systems are employed to protect my personal information and sensitive personal information.

IMPORTANT NOTE: Text messages or conversation between myself and IPAMS staff will not be shared as it is STRICTLY CONFIDENTIAL and only to be used as reference for my application. I understand that posting of SCREENSHOTS in any social media platform is PROHIBITED. I further acknowledge that my application may be SUBJECT FOR DISQUALIFICATION in case I am found to have violated this instruction. This Data Privacy Consent form is duly executed, and I fully understand and voluntarily agree to its contents by affixing my signature below. I also warrant that I have acquired the consent from all parties involved in my application and hold free and harmless and indemnify IPAMS from any complaint, suit or damages, which party may file or claim in relation to issues surrounding my application to IPAMS. PART I – APPLICANT INFORMATION

How did you learn about IPAMS? Job Fair: Date and Venue Please refer to Page 2 - Part II of this application form. TO BE FILLED-OUT BY IPAMS RECRUITMENT TEAM ONLY.

Watch listing: POEA Watchlist: No Record Permanently cleared/Lifted Temporarily Disqualified Employee Relations Department Status: No derogatory record Not Recommended EVALUATION AND RECOMMENDATION

EVALUATED BY: Status: Shortlisted Failed Talent Pool

(Full Name/Signature of recruiter)

Name (Last, First, Middle

Name)

Position Applied Date of Birth (mm/dd/yy)

Email Address Age

Cellphone No. Gender

Backup Cellphone No. Highest Educational Attainment Current Location (City/Province) Passport Validity (mm/dd/yy) Marital Status (Single, Married,

Common-Law, Separated)

NBI Remark as stated

(No Record, No Derogatory or

No Criminal Record)

Height (ft.) & Weight (Kg.) NBI Validity Date (mm/dd/yy) Latest Basic Salary (PHP) PEOS Certificate No.

Recruitment Department Form 002 General Evaluation Form (Back) Revised February 11, 2022

All rights reserved, no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of IPAMS Recruitment Team 2

PART II – MEDICAL STATUS DECLARATION

Please complete this form and declare fully all medical conditions. Failure to do so can mean cancellation of your application. First Name / Middle Name / Family Name

Date of last Medical Examination(MM/DD/YYY) : Name of Medical Facility / Place : Please put a Check under the YES or NO column if you were diagnosed having the following conditions, and indicate treatment /corrective procedures done prior to this application: Other conditions (please specify):

Surgical Operation? YES NO

(if YES, Please indicate what kind of operation and what year)

Currently taking medicine? YES NO

(If yes, please indicate for what illness and generic name of medicine)

Vices ? Smoke/Vape Drinking Alcohol

COVI-19 VACCINE STATUS (Check all if completely vaccinated and state details) CERTIFIED CORRECT:

APPLICANT SIGNATURE / DATE

Medical Condition YES NO Treatment / Corrective Procedure Tuberculosis / PTB

Asthma

Skin Disease(s) / Allergy

Hepatitis “B” (HBSAG)

Hepatitis “C”

Renal / Kidney Disease

Heart Disease

Hypertension

Diabetes

Thyroid Problem

Hernia

Body Tattoos

Vision(specify condition)

Hearing (specify condition)

Scoliosis (indicate degree)

Other Physical Deformities

(ex. Gunshot or stab wounds, trauma, etc.)

1st Shot 2nd Shot Booster No Plans of Getting

Vaccinated

Date: Date: Date: Brand: Brand: Brand: Country: Country: Country:

Contact this candidate