BACKGROUND INVESTIGATION FORM

Please fill all information in PRINTED. If item is not applicable put “N/A”
CANDIDATE’S DETAILS
BAUTISTA MARIA THALIA TABLAN
Applicant's Name: _________________________________________________________________________________
Surname Given Name Complete Middle Name Suffix (Jr./Sr/ III,etc)

SINGLE
Civil Status: ___________________ FEMALE
Gender: ____________ 09/06/2000
Birth Date: (MM/DD/YYYY)_____________________

09530775059
Contact Number: _____________________________ mtbautista03@gmail.com
Email Address: ____________________________________

34-9841848-9
SSS Number: ________________________________ 03-252496893-1
Philhealth Number: _________________________________

1212-7611-5860
Pag-ibig Number: _____________________________ 772-356-629-000
Tax Identification Number: ___________________________

#23 Kaimito st. Payatas B, Quezon city

Current Address: ___________________________________________________________________________________

__________________________________________________________________________________________________
#23 Kaimito st. Payatas B. Quezon City
Permanent Address:_________________________________________________________________________________

__________________________________________________________________________________________________

ADDRESS CHECK

Please provide a sketch of your current address

EMERGENCY CONTACT PERSON:

Contact 1: Mishiel Bautista Relationship: Mother Contact Number: 0926 009 7788

Contact 2: Jimmy Bautista Relationship: Father Contact Number: 0927 433 5603

RELATIVES WORKING IN CONCENTRIX:

Name Relationship Position

n/a

Rev 07.09.2020
 BACKGROUND INVESTIGATION

AUTHORIZATION FOR EDUCATION CHECK

To the Registrar's Office

To whom it may concern:

This is to authorize confirmation and verification of Concentrix, through their official representative, on
my education records based on my declared information below:

Highest Education Attainment:

O Post-Graduate Degree (Doctorate, Masters) O High School Graduate (ALS passer OR old curriculum)
O Post-Graduate Level (Doctorate, Masters) O Senior High School Graduate (K-12)
O College Graduate O K-12 Undergraduate
O 1st year College (Completed OR With back subjects)
/ 2nd year College (Completed OR With back subjects)
O
O 3rd year College (Completed OR With back subjects)
O 4th year College (Completed OR With back subjects)
O Diploma/ Associate/ Vocational Course (specify # of year/s___)

Name of Institution (College/Post Graduate): Centro Escolar University

___________________________________________
9 mendiola st. San Miguel, Manila City
Address / Branch: __________________________________________
735.6861 to 71 / 736.8851 to 54
Contact Details: ___________________________________________
Maria Thalia T. Bautista
Name in school records: ____________________________________
Doctor of Dental Medicine
Degree/Course: _______________________________________________________________________
Date of Graduation (if applicable - for College Graduate only) MM/DD/YYYY: ______/_______/_________
2018 - 01460
Student ID: ________________
06 2018
Dates Attended: From: __________/_________/________To: 06 2020
________/______/_________
MM / DD / YYYY MM / DD / YYYY

Name of Institution (High School):

Southeast Asian College, Inc.
_____________________________________________________________
E. Rodriguez Sr. Avenue, Quezon City
Address / Branch: __________________________________________________
Contact Details: ____________________________________________________
Name in school records: Maria Thalia T. Bautista
_____________________________________________
04 2018
Date of Graduation (if applicable - for High School Graduate only) MM/DD/YYYY: ______/______/_______
GAS2
Student ID: ________________ Section: _______________
06 2016
Dates Attended: From: _________/______/________To: 04 2018
_______/______/_________
MM / DD / YYYY MM / DD / YYYY

Kindly extend due courtesy upon request of relevant information deemed necessary in completion of
the education checks.

Thank you.
MARIA THALIA BAUTISTA 08/11/2022
________________________/_______________________
Signature over Printed Name / Date Signed

Rev 07.09.2020
EMPLOYMENT HISTORY DETAILS
SUPER SHOPPING MARKET, INC.
1. NAME OF ORGANIZATION: ______________________________________________________________________
SM City Fairview Novaliches Quezon City
ADDRESS:____________________________________________________________________________________
10 06 2021
EMPLOYMENT DATE From (MM/DD/YYYY): _______/________/_______To 03 21 2022
(MM/DD/YYYY): ____/______/______
Cashier
POSITION (Upon hiring): ____________________________ Cashier
POSITION (Upon leaving): ______________________
NATURE OF EMPLOYMENT: □
/ Full-Time □ Part-Time □ Self-Employed □ Internship
Abigail Espante
IMMEDIATE SUPERVISOR: _________________________________ CONTACT NUMBER: __________________
Reason for Leaving: ________________________________________ Recruiter Remarks (R/O):_____________

EVER COMMONWEALTH CENTER, INC.

2. NAME OF ORGANIZATION: ______________________________________________________________________
Don Mariano Cor. Don Antonio Quezon City
ADDRESS:____________________________________________________________________________________
12 05 2020
EMPLOYMENT DATE From (MM/DD/YYYY): _______/________/_______To 06 27 2021
(MM/DD/YYYY): ____/______/______
Sales clerk
POSITION (Upon hiring): ____________________________ Sales clerk
POSITION (Upon leaving): ______________________
NATURE OF EMPLOYMENT: □
/ Full-Time □ Part-Time □ Self-Employed □ Internship
Andrew Roperos
IMMEDIATE SUPERVISOR: _________________________________ CONTACT NUMBER: __________________
Reason for Leaving: ________________________________________ Recruiter Remarks (R/O):_____________

3. NAME OF ORGANIZATION: ______________________________________________________________________

ADDRESS:____________________________________________________________________________________
EMPLOYMENT DATE From (MM/DD/YYYY): _______/________/_______To (MM/DD/YYYY): ____/______/______
POSITION (Upon hiring): ____________________________ POSITION (Upon leaving): ______________________
NATURE OF EMPLOYMENT: □ Full-Time □ Part-Time □ Self-Employed □ Internship
IMMEDIATE SUPERVISOR: _________________________________ CONTACT NUMBER: __________________
Reason for Leaving: ________________________________________ Recruiter Remarks (R/O):_____________

4. NAME OF ORGANIZATION: ______________________________________________________________________

ADDRESS:____________________________________________________________________________________
EMPLOYMENT DATE From (MM/DD/YYYY): _______/________/_______To (MM/DD/YYYY): ____/______/______
POSITION (Upon hiring): ____________________________ POSITION (Upon leaving): ______________________
NATURE OF EMPLOYMENT: □ Full-Time □ Part-Time □ Self-Employed □ Internship
IMMEDIATE SUPERVISOR: _________________________________ CONTACT NUMBER: __________________
Reason for Leaving: ________________________________________ Recruiter Remarks (R/O):_____________

5. NAME OF ORGANIZATION: ______________________________________________________________________

ADDRESS:____________________________________________________________________________________
EMPLOYMENT DATE From (MM/DD/YYYY): _______/________/_______To (MM/DD/YYYY): ____/______/______
POSITION (Upon hiring): ____________________________ POSITION (Upon leaving): ______________________
NATURE OF EMPLOYMENT: □ Full-Time □ Part-Time □ Self-Employed □ Internship
IMMEDIATE SUPERVISOR: _________________________________ CONTACT NUMBER: __________________
Reason for Leaving: ________________________________________ Recruiter Remarks (R/O):_____________

NOTE: If you have more than 5 employment history, please ask the Front
desk/Recruiter to provide another sheet of employment history details.

Rev 07.09.2020
PROFESSIONAL CHARACTER REFERENCE

Please provide us details of four (10) professional character references who have known you from your previous
job(s). These character references should be your Immediate Supervisor, Manager, or Colleague.

FOR FRESH GRADUATES: Please provide us details of four (10) character references who have known you in
the last 3 years. (Highschool Teacher / Professors/ Instructors / OJT Supervisor)
Note: Friends and relatives are NOT valid references.

PROFESSIONAL CHARACTER REFERENCE 1

Marvin Atienza
NAME OF REFERENCE ________________________________ Colleague
RELATIONSHIP: ____________________________
Optical Technician
COMPANY & POSITION: ____________________________ 09101038431
CONTACT DETAILS: ____________________________
PROFESSIONAL CHARACTER REFERENCE 2
Dianne Imperial
NAME OF REFERENCE ________________________________ Colleague
RELATIONSHIP: ____________________________
Sales Clerk
COMPANY & POSITION: ____________________________ 09266406957
CONTACT DETAILS: ____________________________
PROFESSIONAL CHARACTER REFERENCE 3
Melissa Soriano
NAME OF REFERENCE ________________________________ Colleague
RELATIONSHIP: ____________________________
SM Cashier
COMPANY & POSITION: ____________________________ 09669609308
CONTACT DETAILS: ____________________________
PROFESSIONAL CHARACTER REFERENCE 4
Jayson Santos
NAME OF REFERENCE ________________________________ Colleague
RELATIONSHIP: ____________________________
SM Bagger
COMPANY & POSITION: ____________________________ 09757852096
CONTACT DETAILS: ____________________________
PROFESSIONAL CHARACTER REFERENCE 5
Rudema Mae Villanueva
NAME OF REFERENCE ________________________________ Colleague
RELATIONSHIP: ____________________________
SM Cashier
COMPANY & POSITION: ____________________________ 09203766927
CONTACT DETAILS: ____________________________
PROFESSIONAL CHARACTER REFERENCE 6
Don Chester Dolorito
NAME OF REFERENCE ________________________________ Colleague
RELATIONSHIP: ____________________________
Sales Clerk
COMPANY & POSITION: ____________________________ 09684242595
CONTACT DETAILS: ____________________________
PROFESSIONAL CHARACTER REFERENCE 7
Arriane Perez
NAME OF REFERENCE ________________________________ Colleague
RELATIONSHIP: ____________________________
sales clerk
COMPANY & POSITION: ____________________________ 09052732943
CONTACT DETAILS: ____________________________
PROFESSIONAL CHARACTER REFERENCE 8
Sofia Parrocha
NAME OF REFERENCE ________________________________ Colleague
RELATIONSHIP: ____________________________
Sales Clerk
COMPANY & POSITION: ____________________________ 09776756126
CONTACT DETAILS: ____________________________
PROFESSIONAL CHARACTER REFERENCE 9
Precious Daco
NAME OF REFERENCE ________________________________ Colleague
RELATIONSHIP: ____________________________
Cashier
COMPANY & POSITION: ____________________________ 09982218185
CONTACT DETAILS: ____________________________
PROFESSIONAL CHARACTER REFERENCE 10
NAME OF REFERENCE ________________________________
Aldrea Colleague
RELATIONSHIP: ____________________________
SM HR assistant
COMPANY & POSITION: ____________________________ 09222735547
CONTACT DETAILS: ____________________________

Rev 07.09.2020
 AUTHORIZATION

I hereby declare that all information provided in this form are true to the best of my knowledge and that any
falsified or malicious information in this application will be sufficient grounds for withdrawal of offer (if
applicant) or dismissal (if employed) upon discovery. I also confirm that all the personal information of other
individuals I provided in this form are provided with their knowledge and consent, and that I undertake to be
responsible to them for my disclosure of their information to Concentrix.

I authorize Concentrix, its agents, representatives and/or third party providers to verify and confirm any and
all information pertinent to my educational, employment and personal background and history, and is not
limited to the information provided in this form ("Purpose"), with my previous employers, school and other
relevant individuals.

I affirm and consent to the disclosure and sharing of my personal information and sensitive personal
information, to Concentrix, its agents, representatives and/or third -party providers, for the said
Purpose.
I hereby release, discharge and hold free and harmless, Concentrix , its agents, representatives and/or
third party providers, and the disclosing individual and/or entity, who holds and controls my personal
information, with regard to any above-mentioned sharing, disclosure and processing of my personal
information and sensitive personal information.
I am executing this form and providing my consent, willingly and voluntarily, without compulsion and
intimidation from the company

MARIA THALIA T. BAUTISTA

PRINTED NAME AND SIGNATURE: DATE: AUGUST 11, 2022

Rev 07.09.2020