GENERAL EVALUATION FORM
TO BE FILLED-OUT BY IPAMS RECRUITMENT TEAM ONLY.
RECOMMENDATION: ☐ Q ☐ NQ ☐ TP APPLICANT’S PREFERRED COUNTRY:
RECRUITER:
ASSESSMENT DATE:
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PERSONAL INFORMATION (APPLICANT PROFILE)
HOW DID YOU LEARN ABOUT IPAMS?
☐
✔ Facebook ☐ Instagram ☐ Twitter/X ☐LinkedIn ☐ Tiktok ☐ Youtube ☐ Website ☐ IPAMS Mobile App
☐ Workabroad.ph ☐ DMW Job Fairs/SRA ☐ PESO Offices ☐ Word of Mouth OTHERS_______________________
PART I – APPLICANT INFORMATION
Position Applied Fast food attendant Current job Safety Administrator
Full Name Bulawan, Nathaniel Grajo
(Last Name) (First Name) (Middle Name)
Block 2 Lot 45 Phase 3A Sagittarius St St Agatha Homes Tikay Malolos Bulacan
Current Address
bulawannathanielg@gmail.co
Cellphone No. 09396921564 m
Email address
Backup Cellphone No. 09309872054
Date of Birth May 19, 1995 Gender ☐
✔ MALE ☐ FEMALE
(Month/Date/Year)
Age
29 Marital status
☐
✔ SINGLE ☐ MARRIED
☐ LIVE-IN/COMMON LAW ☐ ANNULLED
☐ SINGLE-PARENT
Height (cm) & Weight (kg) 168cm / 79kg ☐ LEGALLY SEPARATED ☐ WIDOWED
Passport Number P1376510C Passport Validity August 18, 2032
(Month/Date/Year)
Driver’s License Driver’s License
Restriction Code A,A1 Validity May 19, 2026
(Month/Date/Year)
PEOS Certificate No. DMW-PEOS-0001713742-DW
☐ 2012
✔ College Graduate ______ 2016
- ______ ☐ Associate Degree ______ - ______
☐ Senior High School ______ - ______ ☐ College Undergraduate ______ - ______
Highest Educational ☐ Junior High School ______ - ______ ☐ Graduate Associate Degree Undergraduate ______ - ______
Attainment ☐ High School ______ - ______ ☐ Highschool Undergraduate ______ - ______
☐ ALS Certified ______ - ______ ☐Post-Graduate ______ - ______
☐ Vocational Course/TESDA ______ - ______
*Indicate school year on the space provided
☐ No Record on File ☐✔ No Criminal Record on File NBI Clearance
NBI Clearance Remarks
☐ No Derogatory Record on File ☐
✔ No Pending Case Validity (Month/Date/Year)
ARE YOU AN EX-OFW ☐ YES ☐
✔ NO PREVIOUSLY DEPLOYED BY IPAMS ☐ YES ☐
✔ NO
IF EX-OFW, INDICATE COUNTRY/IES DATE OF LAST OVERSEAS
WHERE YOU WORKED IN THE LAST WORK
(Month/Date/Year)
FIVE (5) YEARS
(LEAVE BLANK FOR FIRST TIMERS)
ANY UNSETTLED DEBTS ☐ YES ☐ NO
OVERSEAS?
DO YOU HAVE A CASE ☐ YES ☐
✔ NO DO YOU HAVE RELATIVES/ ☐ YES ☐
✔ NO
AGAINST YOUR FORMER FAMILY/FRIENDS IN
Employer/DOLE/DMW (POEA)? CANADA?
(IF YES, STATE STATUS) (IF YES, STATE LOCATION)
Please refer to Page 2 – Part II of this application form
PART II – MEDICAL DECLARATION FORM
Recruitment Department Form 002 General Evaluation Form 1
Revised October 24, 2023
All rights reserved, no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic,
mechanical, photocopying, record or otherwise, without the prior written permission of IPAMS Recruitment Team.
Please complete this form and declare fully and honestly all medical/physical conditions you have. Failure to do so can mean cancellation of
your application.
Nathaniel Grajo Bulawan
_____________________________________________________________________________________________________________________
First name Middle name Last name
Date of last Medical Examinations (MM/DD/YYYY):
Name of Medical Facility/Place:
Please put a Check (✓) under the YES or NO column if you were diagnosed of the following conditions, and indicate treatment/corrective
procedures done prior to this application:
Medical Condition YES NO Write Treatment/Corrective Procedure
Vision Problem: EOR/Amblyopia/Cataract ☐ ☐
Color Deficiency: Color Blindness ☐ ☐
Hearing Deafness/Audiometry finding ☐ ☐
Head Injury, Trauma, Acquired Brain Injury ☐ ☐
Neurological: Migraine, Epilepsy, Stroke, Vertigo ☐ ☐
Scoliosis (indicate degree) ☐ ☐
Skin Disease/Allergic Dermatitis/Psoriasis/Eczema ☐ ☐
Thyroid: Goiter/Nodules/Hashimoto’s Disease/Grave’s Disease/Cancer ☐ ☐
Asthma/COPD/Emphysema ☐ ☐
Tuberculosis (PTB/Extrapulmonary) ☐ ☐
Heart Disease/Abnormal ECG/AF/Angioplasty/CABG ☐ ☐
Hypertension ☐ ☐
Diabetes ☐ ☐
Renal/Kidney Disease/Kidney stone/Nephrectomy ☐ ☐
Gastrointestinal Disease/Gastroesophageal Reflux Disease (GERD)/ ☐ ☐
Gallbladder stone/Hemorrhoids
OB-GYN Disorder: PCOS/Dysmenorrhea/Endometriosis ☐ ☐
Hernia ☐ ☐
Hepatitis (Type: A, B, C, D, E) ☐ ☐
STD (HIV, HPV, Syphilis, Chlamydia, Gonorrhea) ☐ ☐
Psychological problem/Anxiety/Depression/PTSD ☐ ☐
Fainting Spell, Dizziness ☐ ☐
Others (please specify) ☐ ☐
Physical/Body Marks YES NO Indicate exact body part
Body Tattoos ☐ ☐
Scars ☐ ☐
Keloids ☐ ☐
Birthmarks ☐ ☐
Amputation (loss or removal of a body part such as a finger, toe, hand, foot, ☐ ☐
arm or leg)
Visible Moles ☐ ☐
Polydactyly (one or more extra fingers) ☐ ☐
Leg Length Discrepancy (one leg shorter than the other) ☐ ☐
Muscular Dystrophy ☐ ☐
Warts ☐ ☐
Skin Tags ☐ ☐
If you have undergone any surgical procedure / operation or removal of tumor/mass, please submit operative record including biopsy /
histopathology and your attending specialist’s medical report to include date, procedure done, and prognosis of condition. (WRITE N/A on
the space if NOT Applicable)
If you are currently taking any medication, please indicate what medicine / drug and for what illness / disease (WRITE N/A on the space if NOT
Applicable)
Are you COVID-19 Full Vaccinated? ☐
✔ YES ☐ NO
Vices? ☐ Smoking/Vaping ☐
✔ Drinking Alcohol
CERTIFIED TRUE & CORRECT:
APPLICANT SIGNATURE / DATE
Recruitment Department Form 002 General Evaluation Form 2
Revised October 24, 2023
All rights reserved, no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic,
mechanical, photocopying, record or otherwise, without the prior written permission of IPAMS Recruitment Team.
PART III - STATEMENTS OF UNDERSTANDING:
I, _________________________________________, applicant for an overseas job, hereby depose and say:
A. FALSIFICATION OF DOCUMENTS AND MISREPRESENTATION OF APPLICATION:
I understand and agree to abide by the Department of Migrant Workers’ 2023 Rules and Regulations particularly on Section 142,
Part VI, Rule 3, to wit:
Disciplinary Action Against OFW, Classification of Offense and Penalties
SECTION 141. Grounds for Disciplinary Action and their Penalties. Commission by an OFW of any of the offenses enumerated
below shall be a ground for disciplinary action for which the corresponding penalties shall be imposed.
1. SERIOUS OFFENSES. Serious offenses are punishable by One (1) Year-and One (1) Day to Two (2) Years suspension from
participation in the overseas employment program.
a. Submitting, furnishing or using falsified document or employing any other forms of misrepresentation for the purpose of job
application or employment.
B. CONFLICT OF INTEREST
I hereby undertake to not engage in any conflict of interest. Should I sign up or have already been selected for a particular
Principal, I am waving my chance to be endorsed to other principals, unless IPAMS would state otherwise.
C. POSSIBLE CONDITIONAL OFFER AND MOBILIZATION PROCESS
I understand and agree that should I fail to meet the Principal’s required physical tests in the Philippines and at the job site
(abroad), or if for any reason, it is determined that I may not be employed, the Principal shall not be held liable for loss or damages.
I also warrant that I have acquired the consent from all parties involved in my application and hold free and harmless and
indemnify IPAMS from any complaint, suit or damages, which party may file or claim in relation to issues surrounding my
application to IPAMS.
D. DATA PRIVACY POLICY
I voluntarily give my consent for the collection, use, processing, storage, and retention of my personal data or information as an
applicant for an overseas or local job. I fully understand that the information provided are solely for recruitment by IPAMS which
will be shared to the Principal for possible employment. This Data Privacy Consent is for the purpose of collection and disclosure
of my relevant personal information and sensitive personal information to be utilized for processing my application, for
documentation, research if applicable, and facilitation of future transaction.
In compliance with Data Privacy Act (DPA) of 2012, and its Implementing Rules and Regulations (IRR) effective since September
8, 2016, I allow and authorize IPAMS to continue to use, retain my information for a period of six (6) months and agree that
my information will be deleted/destroyed after this period. I also understand that my consent does not prevent the existence of
other criteria for lawful processing of personal data in relation to IPAMS’ operations. I also allow IPAMS to share my information
to third parties (government agencies, IPAMS clients and associates – overseas or local employment) which are necessary for any
of IPAMS’ legitimate business purpose with IPAMS’ assurance that security systems are employed to protect my personal
information and sensitive personal information.
Text messages or conversation between myself and IPAMS staff will not be shared as it is STRICTLY CONFIDENTIAL and only to
be used for my application. I understand that SCREENSHOTS and posting them in any social media platform is PROHIBITED.
Such action will be SUBJECT FOR DISQUALIFICATION of my application even if I am chosen as a shortlist candidate for the job
I applied.
APPLICANT SIGNATURE OVER PRINTED NAME DATE
TO BE FILLED-OUT BY IPAMS RECRUITMENT TEAM ONLY.
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Watch listing: DMW Watchlist: ☐ No Record ☐ Permanent Cleared/Lifted ☐ Temporarily Disqualified
Employee Relations Department Status: ☐ No Derogatory Record ☐ Not Recommended
EVALUATION AND RECOMMENDATION
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Recruiter: _______________________________ Assessment Date: ___________________ Status: ☐Q ☐ NQ ☐ TP
(Full Name/Signature of Recruiter)
Recruitment Department Form 002 General Evaluation Form 3
Revised Page 3 April 30, 2024
All rights reserved, no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic,
mechanical, photocopying, record or otherwise, without the prior written permission of IPAMS Recruitment Team.
