Republic of the Philippines

Department of Health
CENTER FOR HEALTH DEVELOPMENT – CARAGA
DATA PROTECTION OFFICE

EMPLOYMENT INFORMATION VERIFICATION FORM

Name of Verifier: ____________________________Date of application: ___________________

Name of office: _____________________________ Position________________________________
Office address: _____________________________________________________________________
Office contact number: _______________ Applicant’s Mobile Number: __________________
PURPOSE OF VERIFICATION:
__________________________________________________________
_____________________________________________________________________________________

Pertinent Information to be verified, (kindly check the box below):

Attendance Photos Date/ Length of employment Status of employment;

Position/ Designation Basic Monthly Salary Area of assignment

Others: (Specify) _______________________________________________________________

x x x x x x x UNDERTAKING x x x x x x x
“I do hereby solemnly swear that the information that I will get out of this verification will not be used
other than the above-stated purpose as applied. And that any violation of my oath consequently
releases the DOH-CHD Caraga and the Data Protection Officer from any and all liability arising
therein”.

_____________________________
(Signature above printed name of verifier)

x x x x x x x CONFORMITY x x x x x x x

“I voluntarily consent the disclosure of my personal information by reason of the above-stated

purpose”.

____________________________
(Signature above printed name of DOH-CHD Caraga Employee)

SIGNED IN THE PRESENCE OF:

ANTONIO C. MEDROSO CESAR C. CASSION, MD, MPH, CESO IV

Data Protection Officer Regional Director IV
All from this Office.

acm 070162020.