CONSENT LETTER in lieu of Data Privacy Act of 2012

Republic Act No. 10173

To whom it may concern,

This is to authorize to release my academic records and/or verify

(School Name)
The authenticity of my school documents in connection with my application for employment.

This is to further authorize the HB6 (Hiring Basix), as the 3rd background checking company of the
company I am applying for, to obtain academic records and/or verify the authenticity of my school
documents from the .
(School Name)

Finally, this is to waive the privacy of academic records and hold ,

(School Name)
its Registrar and school officials, free from any liabilities or damages in connection with the release of
academic records and/or verification of the authenticity of my school documents.

––––––––––––––––––––––––––
Signature over printed name

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Date

1
 CONSENT LETTER in lieu of Data Privacy Act of 2012
Republic Act No. 10173

I hereby grant authorization the employer and any person or organization acting on its behalf to verify information presented in my
application form and to procure a background screening report for that purpose. I understand that such a report may contain
information about my background, character and personal reputation. I further understand and agree that, in the event of my
employment, a background screening report may be procured in connection with subsequent employment decisions.

Upon my written request, I will be advised of the name and address of each employment reporting agency from which an
employment report or investigative report may have been obtained. I also voluntarily authorize HIRING BASIX, vendor of the
employer on its behalf, to perform reference checks of my employment (with the exception of my current employer, unless I have
authorized such contact or commenced employment with Employer) and such other checks and inquiries are necessary in order
to verify information provided by me in my employment application. I hereby release from liability all persons or entities requesting
or supplying such information. Moreover, I understand that my employment with the Firm may be terminated with immediate effect
should any information provided herein be proven untrue.

Full Name: _____________________________

Date of Birth: _____________________________

Identity #: _____________________________
(Valid ID)

Date: _____________________________

Signature: _____________________________