GENERAL EVALUATION FORM

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.

____________________________________ _____________________
APPLICANT SIGNATURE DATE SIGNED
SIGNATURE OVER PRINTED NAME (mm-dd-yy)

PART I – APPLICANT INFORMATION

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, NBI Remark as stated

(No Record, No Derogatory or
Common-Law, Separated) No Criminal Record)

Height (ft.) & Weight (Kg.) NBI Validity Date (mm/dd/yy)

Latest Basic Salary (PHP) PEOS Certificate No.

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)

Recruitment Department Form 002 General Evaluation Form (Front)

Revised February 10, 2022
1
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
 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:
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.)

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)

1st Shot 2nd Shot Booster No Plans of Getting

Vaccinated

Date: __________________ Date: __________________ Date: __________________

Brand: _________________ Brand: _________________ Brand: _________________

Country: _______________ Country: _______________ Country: _______________

CERTIFIED CORRECT:
_______________________________
APPLICANT SIGNATURE / DATE

Recruitment Department Form 002 General Evaluation Form (Back)

Revised February 11, 2022
2
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