Republika ng Pilipinas

Kagawaran ng Kalusugan
PANG-ALAALANG SENTRONG MEDIKAL QUIRINO
(QUIRINO MEMORIAL MEDICAL CENTER)
JP Rizal cor. P. Tuazon Blvd cor Katipunan Road, Project 4, Quezon City, Philippines, 1109
Website : www.doh.gov.ph/qmmc Email add: qmmc_doh@yahoo.com
Trunkline Nos: 5304-9800

AUTHORIZATION FOR BACKGROUND CHECK

(Please read and sign this form in the space provided below. Your written
authorization is necessary for completion of the application process)

I, , hereby authorized the Quirino

Memorial Medical Center(QMMC) to conduct a background check, whether written,
electronic, photographic, digital and /or recording, for purpose of evaluating whether
I am qualified for the position I am applying. I understand that considerable effort on
the part of QMMC may be expended on considering me for the position. Such efforts
may include a personal interview and reference checks exploring my past
performance on the job as well as character reference. This
information/documentation may also contain but is not limited to education,
eligibility, employment title, employment tenure and any other deemed necessary.

I hereby release all persons or entities requesting or supplying such information from
any liability arising such disclosure. I confirm and acknowledge that a photocopy or
scanned through e-mail of this authorization be accepted with the same authority as
original.

I acknowledge that I have read and hereby agree to the collection, use, processing
and transfer of any data about me in accordance with the RA No. 10173 also known
as Data Privacy Act of 2012.

I also understand that I may withhold my permission and that in such case, no
background checking will be done, and my application for employment at the Quirino
Memorial Medical Center will not be processed further.

Signature:

Printed Name:

Date:

Issued ID:

CENTER OF EXCELLENCE