Anti-Terrorist Financing Screening Consent Form

Directions: This form is to be signed by the individual providing their personal data.
PERSONAL INFORMATION
ANIFE MOSQUEDA LANO
First Name Middle Name Last Name
08/28/1987
Maiden and/or Other Names Used Birthdate (MM/DD/YYYY)
☐ Male ☐
■ Female
P-1, ESTADO, MATALAM, N. COTABAT O MATALAM PHILIPPINES 9406 PHILIPPINES
Address City State Zip/Postal Code Country

CONSENT & DISCLOSURE

Innovations for Poverty Action (IPA) is the controller of your personal data. You may contact IPA
at or by phone and email at: dataprotection_ph@poverty-action.org .

I understand that my personal data will be used by IPA for the purpose of cross-referencing terrorist watch lists so
IPA can perform its legal or contractual obligation to not contract, engage, or do business with certain identified
parties (terrorists). If you do not give consent for screening or if IPA confirms that you are on a relevant terrorist watch
list, IPA may not enter into an employment relationship with you, contract with you, or contract with your organization.

The personal information collected by IPA on this form will be used to process the screening along with a copy of valid
passport or copy of valid national identification card if you do not have a passport.

IPA will share your personal data with third party software providers who will store and process your personal data
on behalf of IPA, and who are contractually obligated to keep your personal data confidential subject to appropriate
safeguards to prevent unauthorized disclosure.

By giving your consent, you understand your personal data will be transferred to and used by IPA in the United States,
Canada, and/or .

Your personal data will be retained and stored in accordance with the record retention requirements applicable to
IPA under applicable U.S. laws.

You have the right to revoke this consent, request access to, rectify, erase and restrict the processing of your personal
data by contacting us at the email address above. If you request that your personal data be erased, or revoke your
consent, you (or your company, if you are on the board of directors or senior management team of a company IPA
will be contracting with), will no longer be eligible to have either an employment relationship, or a contractual
relationship IPA, and such revocation will be a notice of immediate termination to any then -existing contractual or
employment relationship between you (or your company) and IPA.

You will be promptly notified at the address provided above should there be any data breach that affects your
personal data provided to IPA.

Please check the appropriate line below, sign, date and return this form by email to hr-philippines@poverty-action.org .

I have read and understand the information provided above and consent to Innovations for Poverty Action (IPA) using
my personal data for the purposes described in this notice and understand that I can revoke my consent at any time
with the mentioned consequences. I also understand that signing is document does not guarantee employment or a
contractual relationship with IPA.
☐ I give consent ☐ I do not give consent

LANO, ANIFE MOSQUEDA 02/12/2024

Full Name (Printed) Signature Date