Consent and Authority to Deduct Form

HR Benefits Form V 1.0

Consent Form and Authority to Deduct

In consideration of being permitted to participate in the On Site Vaccination Activity,

MENDOZA, ENRICO LUIS C.
I, ______________________________________________ ,

1. Acknowledge, agree and represent that I understand the nature of the 2022 Onsite Flu Vaccination benefit and
activity and that I am qualified to participate in such activity;

2. Fully understand that this is a co-share benefit arrangement allowing me to avail the vaccines at a lower
administration cost per vial/dose. Cost per associate is at PHP 100.00 Each vial / dose. Availment includes on-
site vaccine administration.

3. Confirm availment of one vial/dose for me.

4. Agree and allow Sitel Philippines Corp. to deduct via salary deduction, the total amount of One Hundred Pesos
(PHP 100.00) on September 13, 2022 or September 28, 2022.

5. That this activity does not override the original stipulation in our Maxicare benefits but instead this activity is
one which is more practical in terms of vaccine availment given its proximity, organization and most of all, its
low cost;

6. Failure to claim the vaccines on time, or 30 Days after the scheduled administration, I hereby authorize
company to dispose or donate the unclaimed vaccines to a charitable institution of choice. Further, I
understand that the PHP 100.00 per vial/dose is not reimbursable in any case I fail to claim within the specified
period above.

CONFORME:

I confirm that I have read and understood the terms and conditions stipulated in this form. I agree and allow the
Company to facilitate the amount due based on the availed flu vaccine vial/dose via salary on August 13, 2022.

MENDOZA, ENRICO LUIS A.

_____________________________ SEPT. 15, 2022
SIGNATURE ABOVE PRINTED NAME DATE SIGNED

1545133 / VIRGIN AUSTRALIA

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09356570591
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Employee Number & Department Phone/Mobile Number

17 Inaman St., Masambong SFDM, Quezon City

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mendoza.enricoluis007@g
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mail.com
_______________________________________________ ___________________________
Complete Address Email Address

Ground Floor, Sitel Building, One Julia Vargas Avenue HR Benefits 2020
Ortigas Home Depot, Ugong, Pasig City, 1604 Philippines For Internal Use Only
+632.8860.0000 | sitel.com Confidential and Proprietary