DATA PRIVACY CONSENT FORM

We highly value your privacy and are committed to protecting your personal information.
This consent form aims to inform you about the collection, use, and protection of your data.

(Full Name of Participant)

I, ____________________________, hereby consent to the collection of my personal
information by NFJPIA Western Mindanao Council. This includes but is not limited to name,
address, email address, phone number, and date of birth. In compliance with the R.A. 10173 or
the “Data Privacy Act of 2012,” all the information provided in this form shall be:

a. Collected for specified and legitimate purposes only;

b. Processed fairly and lawfully;
c. Adequate and not excessive in relation to the purposes for which they are collected
and processed;
d. Retained only for as long as necessary for the fulfillment of the application; and
e. Treated with confidentiality.

The personal data obtained from this form is entered and stored within the NFJPIA
Western Mindanao Council’s authorized information and communications database and will only
be accessed by those authorized by the organization. By signing below, I acknowledge that I
have read and understood this consent form and agree that the information you entered is true
and correct and you consent to sharing them to NFJPIA Western Mindanao Council and to the
collection, processing, and use of my personal information as described herein.

(Full Name of Participant and Signature Here)

_________________________________
Full Name and Signature

(Date Here)
______________________
Date