BACKGROUND CHECK FORM

1. Please read the form completely before filling it.

2. All Sections should be mandatorily filled. Please write N/A if any of the section is Not Applicable.
3. Provide complete and accurate information.

PERSONAL INFORMATION
Employee Name: (use CAPITAL letters)

(First Name) (Middle Name) (Last Name)

Former Name(s) / Maiden Name (if applicable)

(First Name) (Middle Name) (Last Name)

Date of Birth: Gender: Male Female
Age: Nationality: Mobile/Tel No:
Civil Status: Email:
Place of birth: Valid ID Type & No. (optional):

PLACE OF RESIDENCE
Current Address: House # Street Barangay City State/ Province Country

Prominent Landmark:
Zip Code:
Type of Accommodation: Renting Self-owned Parent-owned Others:
Period of stay at this address: From (Month & Yr.): To (Month & Yr.):

Permanent Address: House # Street Barangay City State/ Province Country

Prominent Landmark:
Zip Code:
Type of Accommodation: Renting Self-owned Parent-owned Others:
Period of stay at this address: From (Month & Yr.): To (Month & Yr.):

PRIMARY CONTACTS
(Address Check References)
Name Address Relationship Contact No.

Page 1 of 4
 BACKGROUND CHECK FORM

EDUCATION DETAILS
Provide details of your highest educational attainment.
School / College / University Name:
Address:
Strand/Course Taken:
From (Month/Year): To (Month/year):
Graduate: Yes No

EMPLOYMENT DETAILS
If applicable, provide details of last 2 employments starting with the most recent employer.
A) Previous Employer 1
Company Name:
Address (main office & branch where worked):

Company Contact Numbers:

Position Title: Employee / ID No:
Employed from (Month & Year): To (Month & Year):
Reporting to (Name of immediate supervisor/manager):
Position: Department:
Contact No. Email:
Nature of Employment: Regular/Permanent Project Based / Fixed Term Others:
Agency Details (if under agency):
Reason(s) for Leaving:
Can we contact your employer? Yes No (if No, provide the reason)
When is the best time to contact employer?

B) Previous Employer 2
Company Name:
Address (main office & branch where worked):

Company Contact Numbers:

Position Title: Employee / ID No:
Employed from (Month & Year): To (Month & Year):
Reporting to (Name of immediate supervisor/manager):
Position: Department:
Contact No. Email:
Nature of Employment: Regular/Permanent Project Based / Fixed Term Others:
Agency Details (if under agency):

Page 2 of 4
 BACKGROUND CHECK FORM

Reason(s) for Leaving:

Can we contact your employer? Yes No (if No, provide the reason)
When is the best time to contact employer?

GAPS IN EMPLOYMENT
Specify all gap(s) in employment(s), if any. Put N/A if none.
Date From Date To Employment Gap Activities

Documents Required for Background Verification

For Education Verification:

 Photocopy of Transcript of Records (TOR) and Diploma.

For Employment Verification:

 Photocopy of Certificate of Employment (COE) for all years of employment mentioned.

For Criminal Records and Database Searches:

 Personal Details of this form must be filled completely and a copy of a valid government issued ID with photo
has to be submitted.

Page 3 of 4
 BACKGROUND CHECK FORM

LETTER OF AUTHORIZATION

I hereby provide my authorization for Conduent Business Services Philippines, Inc. and its third-party background
check service provider Info-vision Research Systems, Inc., to conduct a background check on, and independently
verify and inquire with you and/or your good office information about myself in connection with my job
application/employment with Conduent Business Services Philippines, Inc, including but not limited to, my education,
previous employment, residence, involvement in criminal, civil and administrative proceedings, licenses, certifications,
and other personal attributes, circumstances and records, and such other checks and inquiries that are necessary in
order to verify information provided by me in my job application.

In this regard, kindly provide Info-vision Research Systems, Inc., the foregoing information they may request. I hereby
freely and knowingly consent to you and/your good office disclosing said information to Info-vision Research Systems,
Inc. for the foregoing purpose. I hereby release from liability all persons or entities requesting or supplying such
information.

This authorization and release, in original, faxed, photocopied or electronic form, shall be valid for this and any future
reports and updates that may be requested.

Full Name:

Signature:

Date:

Page 4 of 4