High School Recruitment Team

TO BE FILLED-OUT BY IPAMS RECRUITMENT TEAM ONLY.

RECOMMENDATION: Q NQ TP APPLICANT’S PREFERRED COUNTRY: RECRUITER:

ASSESSMENT DATE:

PERSONAL INFORMATION (APPLICANT PROFILE)

HOW DID YOU LEARN ABOUT IPAMS?

Facebook Instagram Twitter/X LinkedIn Tiktok Youtube Website IPAMS Mobile App

Workabroad.ph DMW Job Fairs/SRA PESO Offices Word of Mouth OTHERS PART I – APPLICANT INFORMATION

Position Applied Current job

Full Name

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

Current Address

Cellphone No.

Email address

Backup Cellphone No.

Date of Birth

(Month/Date/Year)

Gender MALE FEMALE

Age

Marital status

SINGLE MARRIED SINGLE-PARENT

LIVE-IN/COMMON LAW ANNULLED

Height (cm) & Weight (kg) LEGALLY SEPARATED WIDOWED Passport Number Passport Validity

(Month/Date/Year)

Driver’s License

Restriction Code

Driver’s License

Validity

(Month/Date/Year)

PEOS Certificate No.

Highest Educational

Attainment

College Graduate - Associate Degree -

Senior High School - College Undergraduate -

Junior High School - Graduate Associate Degree Undergraduate -

High School - Highschool Undergraduate -

ALS Certified - Post-Graduate -

Vocational Course/TESDA -

NBI Clearance Remarks

No Record on File No Criminal Record on File

No Derogatory Record on File No Pending Case

NBI Clearance

Validity

(Month/Date/Year)

ARE YOU AN EX-OFW YES NO PREVIOUSLY DEPLOYED BY IPAMS YES NO IF EX-OFW, INDICATE COUNTRY/IES

WHERE YOU WORKED IN THE LAST

FIVE (5) YEARS

(LEAVE BLANK FOR FIRST TIMERS)

DATE OF LAST OVERSEAS

WORK

(Month/Date/Year)

ANY UNSETTLED DEBTS

OVERSEAS?

YES NO

DO YOU HAVE A CASE

AGAINST YOUR FORMER

Employer/DOLE/DMW (POEA)?

(IF YES, STATE STATUS)

YES NO DO YOU HAVE RELATIVES/

FAMILY/FRIENDS IN

CANADA?

(IF YES, STATE LOCATION)

YES NO

Please refer to Page 2 – Part II of this application form PART II – MEDICAL DECLARATION FORM

*Indicate school year on the space provided

1

Recruitment Department Form 002 General Evaluation Form Revised October 24, 2023

All rights reserved, no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, record or otherwise, without the prior written permission of IPAMS Recruitment Team. GENERAL EVALUATION FORM

Please complete this form and declare fully and honestly all medical/physical conditions you have. Failure to do so can mean cancellation of your application.

Date of last Medical Examinations (MM/DD/YYYY):

Name of Medical Facility/Place:

Please put a Check under the YES or NO column if you were diagnosed of the following conditions, and indicate treatment/corrective procedures done prior to this application:

Medical Condition YES NO Write Treatment/Corrective Procedure Vision Problem: EOR/Amblyopia/Cataract

Color Deficiency: Color Blindness

Hearing Deafness/Audiometry finding

Head Injury, Trauma, Acquired Brain Injury

Neurological: Migraine, Epilepsy, Stroke, Vertigo Scoliosis (indicate degree)

Skin Disease/Allergic Dermatitis/Psoriasis/Eczema Thyroid: Goiter/Nodules/Hashimoto’s Disease/Grave’s Disease/Cancer Asthma/COPD/Emphysema

Tuberculosis (PTB/Extrapulmonary)

Heart Disease/Abnormal ECG/AF/Angioplasty/CABG Hypertension

Diabetes

Renal/Kidney Disease/Kidney stone/Nephrectomy

Gastrointestinal Disease/Gastroesophageal Reflux Disease (GERD)/ Gallbladder stone/Hemorrhoids

OB-GYN Disorder: PCOS/Dysmenorrhea/Endometriosis Hernia

Hepatitis (Type: A, B, C, D, E)

STD (HIV, HPV, Syphilis, Chlamydia, Gonorrhea) Psychological problem/Anxiety/Depression/PTSD

Fainting Spell, Dizziness

Others (please specify)

Physical/Body Marks YES NO Indicate exact body part Body Tattoos

Scars

Keloids

Birthmarks

Amputation (loss or removal of a body part such as a finger, toe, hand, foot, arm or leg)

Visible Moles

Polydactyly (one or more extra fingers)

Leg Length Discrepancy (one leg shorter than the other) Muscular Dystrophy

Warts

Skin Tags

If you have undergone any surgical procedure / operation or removal of tumor/mass, please submit operative record including biopsy / histopathology and your attending specialist’s medical report to include date, procedure done, and prognosis of condition. (WRITE N/A on the space if NOT Applicable)

If you are currently taking any medication, please indicate what medicine / drug and for what illness / disease (WRITE N/A on the space if NOT Applicable)

Are you COVID-19 Full Vaccinated? YES NO

Vices? Smoking/Vaping Drinking Alcohol

First name Middle name Last name

2

CERTIFIED TRUE & CORRECT:

APPLICANT SIGNATURE / DATE

Recruitment Department Form 002 General Evaluation Form Revised October 24, 2023

All rights reserved, no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, record or otherwise, without the prior written permission of IPAMS Recruitment Team. PART III - STATEMENTS OF UNDERSTANDING:

I,, applicant for an overseas job, hereby depose and say: A. FALSIFICATION OF DOCUMENTS AND MISREPRESENTATION OF APPLICATION: I understand and agree to abide by the Department of Migrant Workers’ 2023 Rules and Regulations particularly on Section 142, Part VI, Rule 3, to wit:

Disciplinary Action Against OFW, Classification of Offense and Penalties SECTION 141. Grounds for Disciplinary Action and their Penalties. Commission by an OFW of any of the offenses enumerated below shall be a ground for disciplinary action for which the corresponding penalties shall be imposed. 1. SERIOUS OFFENSES. Serious offenses are punishable by One (1) Year-and One (1) Day to Two (2) Years suspension from participation in the overseas employment program.

a. Submitting, furnishing or using falsified document or employing any other forms of misrepresentation for the purpose of job application or employment.

B. CONFLICT OF INTEREST

I hereby undertake to not engage in any conflict of interest. Should I sign up or have already been selected for a particular Principal, I am waving my chance to be endorsed to other principals, unless IPAMS would state otherwise. C. POSSIBLE CONDITIONAL OFFER AND MOBILIZATION PROCESS I understand and agree that should I fail to meet the Principal’s required physical tests in the Philippines and at the job site

(abroad), or if for any reason, it is determined that I may not be employed, the Principal shall not be held liable for loss or damages. 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.

D. DATA PRIVACY POLICY

I voluntarily give my consent for the collection, use, processing, storage, and retention of my personal data or information as an applicant for an overseas or local job. I fully understand that the information provided are solely for recruitment by IPAMS which will be shared to the Principal for possible employment. This Data Privacy Consent is for the purpose of collection and disclosure of my relevant personal information and sensitive personal information to be utilized for processing my application, for documentation, research if applicable, and facilitation of future transaction. In compliance with Data Privacy Act (DPA) of 2012, and its Implementing Rules and Regulations (IRR) effective since September 8, 2016, I allow and authorize IPAMS to continue to use, retain my information for a period of six (6) months and agree that my information will be deleted/destroyed after this period. I also understand that my consent does not prevent the existence of other criteria for lawful processing of personal data in relation to IPAMS’ operations. I also allow IPAMS to share my information to third parties (government agencies, IPAMS clients and associates – overseas or local employment) which are necessary for any of IPAMS’ legitimate business purpose with IPAMS’ assurance that security systems are employed to protect my personal information and sensitive personal information.

Text messages or conversation between myself and IPAMS staff will not be shared as it is STRICTLY CONFIDENTIAL and only to be used for my application. I understand that SCREENSHOTS and posting them in any social media platform is PROHIBITED. Such action will be SUBJECT FOR DISQUALIFICATION of my application even if I am chosen as a shortlist candidate for the job I applied.

TO BE FILLED-OUT BY IPAMS RECRUITMENT TEAM ONLY.

Watch listing: DMW Watchlist: No Record Permanent Cleared/Lifted Temporarily Disqualified Employee Relations Department Status: No Derogatory Record Not Recommended EVALUATION AND RECOMMENDATION

Recruiter: Assessment Date: Status: Q NQ TP APPLICANT SIGNATURE OVER PRINTED NAME

3

Recruitment Department Form 002 General Evaluation Form Revised Page 3 April 30, 2024

All rights reserved, no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, record or otherwise, without the prior written permission of IPAMS Recruitment Team.

(Full Name/Signature of Recruiter)

DATE

Contact this candidate