Updated 03062023

DATA PRIVACY CONSENT FORM

The City Government of Valenzuela recognizes its duty to protect the data privacy
rights of data subjects as part of its efforts to take effective measures toward good
governance and accountability to people. However, in line with its efforts to
continuously inform its constituents and actively promote Valenzuela City through
quality social media content, it needs to collect, store, access, and process personal
data of ______________________________ in filming of infomercials, bulletins, and
the likes. This will include personal and sensitive personal information such as, but not
limited to, full name, home address, gender, e-mail address, photographs, identification
cards, contact numbers, and other details as may be required by the City Government
of Valenzuela.

In support of such initiatives, I voluntarily give my consent to process my personal and

sensitive personal information mentioned above including the disclosure of such
information in social media platforms in relation with Section 12(a) of the R.A. 10173
otherwise known as the Data Privacy Law of 2012 for the purpose of aiding the City
Government in its efforts to continuously inform its constituents and actively promote
Valenzuela City through quality social media content. I further manifest that I am aware
of my rights under the Data Privacy Law, specifically my right to be informed, object to
processing, access and rectify, suspend or withdraw my personal data, and be
indemnified in case of damages and despite such knowledge, I voluntary give my
consent to process my personal information.

_____________________________
Name of Data Subject/Interviewee

Age: ________
Date _____________

Address: _____________________________
Contact Number: _______________________

Signed in the presence of:

_____________________________ _______________________________
Interviewer Interviewer