GENERAL EVALUATION FORM

PERSONAL INFORMATION (CANDIDATE PROFILE)

Data Privacy Consent:
I,______________________________________ have read this form and understand its contents and voluntarily give my
consent for the collection, use, processing, storage, and retention of my personal data or information. 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, that 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’ operation. I also allow IPAMS to share my
information to third parties 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.
This Data Privacy Consent form was duly executed, and I fully understand and voluntarily agree as to its contents by affixing
my signature below. 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.
____________________________________ _____________________
APPLICANT SIGNATURE DATE SIGNED
SIGNATURE OVER PRINTED NAME (mm-dd-yy)

PART I – APPLICANT INFORMATION

Name (Last, First, Middle

Name)

Position Applied For Date of Birth (mm/dd/yy)

Email Address Age

Cellphone No. Gender

Highest Educational
Backup Cellphone No.
Attainment
Current Location
Passport Validity (mm/dd/yy)
(City/Province)
Marital Status (Single, NBI Remark
Married, Common-Law, (No Record, No Derogatory or
Separated) No Criminal Record)
Height (ft.) & Weight (Kg.) NBI Validity (mm/dd/yy)

Latest - Basic Salary (PHP) PEOS Certificate No.

How did you know IPAMS? ___________________ Job Fair: Date and Venue _________________
Please refer to Page 2 - Part II of this application form.

TO BE FILLED-OUT BY IPAMS RECRUITMENT TEAM

Watch listing: POEA Watchlist: No Record Permanently cleared/Lifted Temporarily Disqualified

Employee Relations Status: No Significant Record with Record

EVALUATION AND RECOMMENDATION

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

EVALUATED BY: _________________________ Status: Shortlisted ____Failed ____ For manpower pooling____
Recruitment Department Form 001 General Evaluation Form (Front)
Revised June 25, 2021
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, recording or otherwise, without the prior written permission of IPAMS Recruitment Team
 APPLICANT SIGNATURE DATE SIGNED
SIGNATURE OVER PRINTED NAME (mm-dd-yy)

PART II – MEDICAL STATUS DECLARATION

____________________________________________________________________________
First Name / Middle Name / Family Name

Please complete this form and declare fully all medical conditions. Failure to do so can mean
cancellation of your application.

Date of last Medical Examinations: _____________________________________

Name of Medical Facility / Place : ____________________________________
Please put a Check (√) under the YES or NO column if you were diagnosed having
the following conditions, and indicate treatment /corrective procedures done prior to this application:

Medical Condition YES NO Treatment / Corrective

Procedure
Tuberculosis / PTB
Asthma
Skin Disease(s) / Allergy
Hepatitis “B” (HBSAG)
Hepatitis “C”
Renal / Kidney Disease
Heart Disease
Hypertension
Diabetes
Thyroid Problem
Hernia
Body Tattoos
Vision(specify condition)
Hearing (specify condition)
Scoliosis (indicate degree)
Other Physical Deformities
(ex. Gunshot or stab wounds, trauma, etc.)

Other conditions (please specify): _______________________________

 If you have undergone surgical operation, please explain and

Indicate the date, nature and other information
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
 If you are currently taking any medication, please indicate what
Medicine / drug and for what illness / disease
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

 If have you have any vices (smoking, drinking etc.)

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

CERTIFIED CORRECT:

________________________________________
Recruitment Department Form 001 General Evaluation Form (Back)
Revised June 25, 2021
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, recording or otherwise, without the prior written permission of IPAMS Recruitment Team
 GENERAL EVALUATION FORM

APPLICANT SIGNATURE / DATE

Recruitment Department Form 001 General Evaluation Form (Front)

Revised June 25, 2021
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, recording or otherwise, without the prior written permission of IPAMS Recruitment Team