Fill out all blanks and checkboxes completely.

Restricted Background Verification Consent Form

Counter-sign any type of erasure.
Background Verification Consent Form/
Date Accomplished (05/07/2021) /
√
Name Cortez, Charlene Mae Bautista

Last Name First Name Middle Name

Signature_______________________________________________
Provide all other and previous full name/s used (e.g. maiden name, aliases, etc.)
(1)

Date ______________________________
Last Name First Name Middle Name

(2)
Last Name First Name Middle Name

(3)
Last Name First Name Middle Name

Civil Status Single √

Married
Country of Citizenship________________________ City _______________State/ Region _______________

Printed Name__________________________________________________
Country of Birth _____________________________ City _______________State/ Region _______________ Permanet
Country of Residence ________________________________________
Current Address

House No., Street Name

Barangay Town/City Zip

Permanent Address  Same as Current Address

House No., Street Name

Barangay Town/City Zip

Phone numbers Landline Mobile

Other contact numbers Email Address_______________________

Identification. Present at least one of the following and provide a photocopy. ID must have a photo. Enricle the type of ID presented

Social Security Passport Voter's ID Senior Citizen Seaman's Book / OFW ID PRC
Driver's License Postal ID GSIS ID ACR POEA/ OWWA Cert IBP ID

Do you have a passport issued by the Philippines?  Yes  No

Have you been issued a passport by another country?  Yes √ No
If yes, please provide the following information:
Passport Number ___________________________________
Place of issue ___________________ Issuance date: _________________ Expiration date: __________________
Do you have dual or multiple citizenship?  Yes √ No
If yes, please provide the following information:
Country _________________________ Country Identification Number _________________________
List all visas that have been issued to you
_________________________________________________none___________________________________________________

Have you ever been convicted of a criminal offense?  Yes  No√

If yes, please explain the charges: (Use an additional sheet of paper if necessary)

What city, country and year did the convictions occur?

Education
Name and Location of School Years Attended Degree
Primary

High School

College/ Vocational Education

Graduate, Post Graduate

 Revised v2.0 TELUS International Philippines Page 1 of 2 July 2014 Fill out all blanks and checkboxes completely. Restricted Background
Verification Consent Form
Counter-sign any type of erasure.
I hereby authorize TELUS International Philippines to perform a background verification as it pertains to employment, which may include, but
is not limited to: identity verification, criminal records check, experience, employment and academic verification; and background and
reference checks. I understand that any false or misleading information given in this application, interviews, correspondence or discussions,
may result in rejection of my application; and in the event of employment, may result in termination.

Printed Name

Signature Date

Revised v2.0 TELUS International Philippines Page 2 of 2 July 2014

Declaration: I _____________________________________ hereby authorize < Telus International
Philippines, Inc. > or any of its affiliates, and any persons or organizations acting on its behalf to verify
information presented in my employment application and to procure an employment report or an investigative
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, an
employment report or investigative report may be procured in connection with subsequent employment
decisions. I also voluntarily authorize MAQResearch Inc. to perform reference checks of my employment and
such other checks and inquiries as 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.

_____________________________ _________________

Signature (SGD) Original Date

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXX
Date: __________________________________

Office of the Registrar

_______________________________________________
_______________________________________________

Gentlemen:

This is with regards to my application for employment with <

__________________________________________ >
I respectfully request the following information to be verified and certified if possible in behalf of its Verification
Company.

1.Full Name: ____________________________________________________

2.Course/s ____________________________________________________
3.Date of ____________________________________________________
Graduation
4.Inclusive ____________________________________________________
Date of
Attendance

Looking forward to your continuous support and guidance.

Very truly yours,

____________________________________________
Full Name and Signature
(For female applicant, kindly specify your Maiden Name)

MAQResearch Inc. respects data subjects and operates in compliance with applicable laws on Data
Privacy Protection and Data Security, specifically, the Data Privacy Act of 2012 (“R.A. 10173”) of the
Republic of the Philippines. This Data Privacy and Protection Policy reinforces compliance with the
national law and it’s implementing rules and regulations.