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IPAMS General Evaluation Form
IPAMS General Evaluation Form
This Data Privacy Consent form is duly executed, and I fully understand and voluntarily agree 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.
Leicel John Alfonso Belmes
____________________________________ January 3, 2023
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APPLICANT SIGNATURE DATE SIGNED
SIGNATURE OVER PRINTED NAME (mm-dd-yy)
Facebook
How did you learn about IPAMS? ___________________ Job Fair: Date and Venue ___________________
Please refer to Page 2 - Part II of this application form.
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Please complete this form and declare fully all medical conditions. Failure to do so can mean cancellation of your application.
12/1/2022
Date of last Medical Examination(MM/DD/YYY) : _____________________________________
Name of Medical Facility / Place : ____________________________________
Klinika Project 7
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.) ✔
N/A
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(If yes, please indicate for what illness and generic name of medicine)
N/A
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Vices ? Smoke/Vape Drinking Alcohol
COVI-19 VACCINE STATUS (Check all if completely vaccinated and state details)
04/27/2021
Date: __________________ 05/25/2021
Date: __________________ 5/10/2022
Date: __________________
Sinovac
Brand: _________________ Sinovac
Brand: _________________ Pfizer
Brand: _________________
Philippines
Country: _______________ Philippines
Country: _______________ Philippines
Country: _______________
CERTIFIED CORRECT:
January 3, 2023
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APPLICANT SIGNATURE / DATE