APPLICATION FORM
Date of Posting of Notice of Vacancy: ___________ HRD Memo No. _____________
Order of Item No. Position Title JG Office/Department
Preference
Name:
Present Position/JG
Employment Status
Office/Department/Agency
CONTACT DETAILS
The HRD shall send all notices relative to your application to the email address you will be
providing below.
Email Address : ______________________________________________
AUTHORITY TO CONDUCT BACKGROUND CHECKS
AND DECLARATION OF PRACTICE PROFESSION
I hereby authorize PhilHealth to make inquiry about and receive information about my
suitability for employment. I give permission to persons contacted to provide information,
which may include, but are not limited to the quality and quantity of my work, work record,
qualifications, education, and disciplinary records. I hereby waive, release and agree not
to sue any person or organization for any result of providing, obtaining or acting upon such
information. I understand that such information is sought with confidentiality, and I will
not request copies of such information.
I also declare that I am not barred/suspended or with ongoing case with penalty of
suspension/disbarment from practicing my profession as
________________________________ (applicable only to applicants to position
with practice of profession e.g. Lawyers, Doctors, Engineers etc.).
A copy of this authorization and declaration shall be effective as the original.
Signature of applicant : ____________________________
Date signed : ____________________________
