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Background Investigation Authorization Form
04/ 06/ 2014
Name
Valencia John Henry Omaoeng
Last Name First Name Middle Name
Provide also other or previous name/s used (e.g. maiden name):
Last Name First Name Middle Name
Date of Birth (mm/dd/yyyy) 08/ 16/ 2014 Single
Married
Current Address
935 - E Banahaw Street
House No., Street Name
Highwayhills Mandaluyong City 1500
Barangay Town/City Zip
Permanent Address Same as Current Address
736 National Road
House No., Street Name
Luz Limay 2103
Barangay Town/City Zip
Contact Information Landline (047) 633 94 26 Mobile 09245641608Email [email protected]
Identification. Present at least one of the following and provide a photocopy. ID must have a photo.
Passport Voter's ID Senior Citizen Seaman's Book PRC OFW ID
Postal ID GSIS ID ACR POEA/ OWWA Cert IBP ID
Have you ever been convicted of a criminal offense? Yes No
If yes, please explain the charges: (Use an additional sheet of paper if necessary)
What city, country and year did the convictions occur?
Education
Primary
Lamao Elementary School 1998 - 2004
High School
Lamao National High School 2004 - 2008
College/ Vocational Education
Bataan Peninsula State University 2008 - 2012 BS in Nursing
Graduate, Post Graduate
University of Santo Tomas 2013 - present MA in Nursing
Employment/ Work ExperienceCurrent Employer
Name & Address of Employer
Former EmployerName & Address of Employer
Civil Status
________________
Date/Month Year Salary Last Position Held
__________________ ________________________________ _______________ _______________________
________________
July 2012 - April 2013 FS Philippines Inc. 15000 HR Officer
__________________ ________________________________ _______________
Last Position Held
Relocation
Reason for Leaving
Salary
24-Hour HR Process Outsourcing 22000 HR Specialist III Schedule
Reason for Leaving
Degree
_______________________
Date Accomplished (mm/dd/yyyy)
Social Security
Driver's License
Years AttendedName and Location of School
Other contact numbers
Date/Month Year
May 2013 - Dec. 2013
Former EmployerName & Address of Employer
Former Employer
Name & Address of Employer
Skills Training/Certification, Volunteer Work, On-the-Job Training, etc.
Date/Month Year
April 2014 Basic Life Support University of Santo Tomas Hospital
April 2014 Advanced Cardiac Life Support University of Santo Tomas Hospital
december 2012 Basic Intravenous Therapy University of Santo Tomas Hospital
ReferencesProvide at least 5 references from your current and most recent employers. If you have no previous work experience, provide character references except family members.
1. Current Employer Yes No If yes, may we contact your current employer? Yes No
Name Sandra Krissel Domingo
Job Title Nurse Supervisor
Company's Name FS Philippines
Company's Address Limay Bataan
Phone Number 09467021915 Other Phone Numbers
Email Address
2. Name Elvira Q. Lozano MA in Nursing Classmate
Job Title Medical officer III
Company's Name Philippine Heart Center
Company's Address Quezon City
Phone Number 09194292928 Other Phone Numbers
Email Address
3. Name Gracie Bagamasbad
Job Title
Company's Name
Company's Address
Phone Number Other Phone Numbers
Email Address
4. Name
Job Title
Company's Name
Company's Address
Phone Number Other Phone Numbers
Email Address
5. Name
Job Title
Company's Name
Company's Address
Phone Number Other Phone Numbers
Email Address
Printed Name
Mobile Number
_______________________
I hereby authorize TELUS International Philippines to perform a background investigation as it pertains to employment, which may include,
but is not limited to: a criminal records check, experience, employment and academic verification; and background and reference checks. I
understand that any false or misleading information given in this application, interviews, correspondence or discussions, may result in
rejection of my application; and in the event of employment, may result in termination.
Mobile Number
Your relation to this
reference
Your relation to this
reference
Your relation to this
reference
Mobile Number
Mobile Number
Mobile Number
Your relation to this
reference
__________________ ________________________________
__________________ ________________________________
________________
Your relation to this
reference
_______________
_______________ ________________ _______________________
__________________ ________________________________ _______________
Date/Month Year Salary
Salary Last Position Held
________________
Not Applicable
_________________________________________ ________________________________ _______________ ________________
Type/Name of Training/Course Name of Company/Organization
_______________________
Reason for LeavingLast Position Held
Reason for LeavingDate/Month Year
Signature Date