Annex E

BACKGROUND CHECK FORM

EMPLOYEE PERSONAL INFORMATION

NAME
Chua, Jheallaine Andrea
_____________________________________________________________________________
Dela peña
(Last Name) (First Name) (Middle Name)

PRESENT
ADDRESS 6340 Waling waling st Camarin II Area D Caloocan City

PERMANENT
ADDRESS
6340 Waling waling st Camarin II Area D Caloocan City

DATE OF BIRTH
11/30/1997
CITIZENSHIP Filipino

ACKNOWLEDGMENT AND CONSENT

By signing below and submitting this form, I understand and agree that, as part of the employment
selection and onboarding process, I shall undergo a background investigation commissioned by Everise
(the “Company”) to confirm my identity and validate my stated qualifications and fitness for employment
with the Company. The investigation shall cover inquiry of identity, financial records and criminal records
check.

I hereby agree for the Company to collect, use, transfer and other process personal information about me
consistent with the Privacy Statement found in Annex C of the Job Offer Letter. I also acknowledge that
under the Philippine Data Privacy Act of 2012 and other privacy regulations , some personal information
can be collected, transferred or disclosed without my consent and that the Company reserves the right to
undertake such activity, when appropriate. To the extent that I have provided (or will provide) personal
information to the Company about dependents or family members, I certify that I have obtained their
consent to the use (including transfer and disclosure) of their personal information consistent with these
statements, and for any individuals not legally competent to give consent, I consent on their behalf and
confirm that I have authority to do so.

I further declare that all information provided in this form are true to the best of my knowledge and that
any false or malicious information in this form or in my application documents, or any omission which is
misleading will be sufficient grounds for revocation of or termination from employment upon discovery.

SIGNATURE: DATE:
08/23/2023
Jheallaine Andrea Chua

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