Reference Check Consent and Release Waiver

I,________________________, hereby authorize Scrubbed.net Global Services Inc. to obtain information

regarding myself through a reference check for purposes of evaluating whether I am qualified for the position I
am being considered.

I, the undersigned, give my consent to obtain this information either in writing or via phone call in connection
with my application. Any person, firm, or organization that will be provided in accordance with this waiver will be
released from any claims of liability for compliance. I understand that my personal information is protected by
the Data Privacy Act of 2012 (R.A. 10173) and will be kept strictly confidential.

Following are my three (3) character references:

Name Company Email Address Contact Number

1. Former Classmate - anyone who can provide insight into my work ethic and previous school
performance/achievements.

2. Former College Professor – someonewho can provide evaluation on my school performance during
college.

3. Workmate/Superior during Internship - any people who spent time working with me and overseeing
my performance on my practicum/OJT.

I acknowledge that all the information that will be provided to Scrubbed HR will be treated as confidential.

Signature over Printed Name

Date: