HUMAN RESOURCES GROUP

TALENT ACQUISITION (TA) DEPARTMENT

JOB APPLICATION FORM

CONSENT / WAIVER / RELEASE FORM

I, ______________________________________, hereby authorize my employer, St. Luke’s Medical Center, and / or its authorized
officers / personnel to collect, record, store, update, use, and / or process in any other manner (“processing”) my personal and
sensitive personal information (“personal information”) such as the following :

a. Full Name
b. Dependent’s Name, age, gender
c. Government ID
d. Date of birth and age
e. Gender
f. Medical availment type
g. Diagnosis /illness

These information as defined under the Data Privacy Act of 2012 or any of its amendments or implementing regulations now or in
the future, insofar as such processing is necessary in relation to and in fulfillment of the terms and conditions of my employment
with SLMC, including but not limited to the use and disclosure of such personal information for purposes of obtaining a health care
benefits and other benefits on my behalf and those of my beneficiaries / dependents that I have declared in relation to their
“personal information.”

I hereby warrant that I am duly authorized to disclose the personal information of my beneficiaries / dependents and I hereby
consent to the processing of such personal information in relation to any government mandated benefits and other employee-
related benefits provided by SLMC. None of my beneficiaries/dependents shall dispute the validity, enforceability or operations-
related thereto nor contest the validity or legality of the disclosure of their personal information in connection therewith.

Further, I hereby fully understand and consent to the processing of my “personal information” by SLMC whenever necessary or
required by any law, regulation or professional standards.

SLMC will at all times respect and abide by applicable laws, regulations and privacy principles in the collection, handling, storage
and disclosure of my personal information for purposes of fulfilling the terms and conditions of my employment with SLMC,
including the use and disclosure of such personal information for purposes of obtaining a health care benefits and other benefits on
my behalf and those of my beneficiaries/dependents that I have declared in relation to their personal information (“purpose”).

Finally, I, and my declared beneficiaries/dependents, hereby waive and release any demand, claim, or complaint of whatever
nature arising from or relating to any damage or liability that may arise from the processing of my / our personal information by
SLMC and all of its directors, officers / personnel, and any of its authorized third-party service providers.

My consent or authorization is revoked at the termination of my employment, resignation or retirement from SLMC.

Candidate
(Please print your full name including middle initial & sign)
Date:
 APPLICATION DETAILS
Position Applied For Location Application Date
1st Choice:

 Quezon City
2nd Choice
 Global City
PHOTO
From where did you learn about the company?
 Walk-in  Roadshow/Career Fair
 Job Advertisements  Referred by: ______________________________________________
 Job Sites / SLMC Careers  Others: __________________________________________________
PERSONAL INFORMATION
Last Name First Name Middle Name Nickname

Present Address Contact Number

House No. / Floor, Building , Street, Village/Barangay, Municipality/City, Province, Zip Code

Permanent / Provincial Address Contact Number

House No. / Floor, Building , Street, Village/Barangay, Municipality/City, Province, Zip Code

Date of Birth Age Gender Civil Status Email Address Mobile Number
MM / DD / YYYY
 Male  Single  Widowed
 Female  Married  Separated
Height: Weight: TAX ID No. SSS No. PAG-IBIG No. PHILHEALTH No.
(ft-in) (lbs)

Language Spoken PRC License No. Valid from Valid to

 Filipino  English
 Others: _____________________
Contact Person in case of Emergency Relation to Candidate Telephone / Mobile Number
Complete Name

Address

PROFESSIONAL BACKGROUND
(Please start from the most recent)

Tenure (From-To) Name of Organization Position Reason for Leaving Salary

EDUCATIONAL BACKGROUND
Level Degree / Program Academic Institution Inclusive Dates Awards / Honors

Graduate Studies

College

Vocational / Trade
Courses

High School
 TRAININGS AND SEMINARS
Program Title Conducted By Inclusive Dates (From-To / Date Completed)

SKILLS AND COMPETENCIES

Behavioral Skills Technical Skills

PROFESSIONAL CERTIFICATIONS AND AFFILIATIONS

Government Examinations / Affiliations Inclusive Dates (From-To / Date Completed) Rating / Rank / Position

FAMILY BACKGROUND
Relationship Name Employer / School Occupation / Degree
Father

Mother

Siblings

Spouse

Children

ADDITIONAL INFORMATION
Kindly answer the following questions by checking the boxes in each row YES NO Details
If yes, please specify details
Do you have on-going applications with other companies?
If yes, please specify the position and inclusive dates of employment
Did you previously apply for a position in St. Luke’s Medical Center
If yes, please specify name of Associate and relationship
Are you related to or acquainted with anyone currently or previously employed in St.
Luke’s Medical Center?
If yes, please specify details
Do you or did you ever had a serious injury or chronic illness?
If yes, please specify details
Have you ever been the object of a written complaint filed with/by previous employer
and/or any government office due to misconduct?
If yes, please specify details
Have you been terminated or dismissed by any of your previous Employer/s?
If yes, please specify details
Have you ever been convicted of any criminal, civil, labor or administrative case?
If yes, please specify details
Do you have any pending criminal, civil, labor or administrative case?
Comments
Are you willing to work on shifts, overtime, or on holidays?
Comments
Are you willing to be re-assigned to another unit/department/group?

CHARACTER REFERENCE
Name Designation Company / Organization Contact Information

DECLARATION

I certify that all information stated herein are true and complete to the best of my knowledge. I
understand that this form part of my pre-employment requirements. Any misrepresentation or
omission of facts shall be sufficient grounds for St. Luke’s Medical Center to discontinue the
processing of my job application or employment which may be a just cause for separation.
Signature over Printed Name of Candidate & Date
 WAIVER AND ACKNOWLEDGEMENT

This is to formally acknowledge the pending medical requirements of the Associates’ Health Clinic in my Pre-
employment Physical Examination.

In light of my earnest intent however to pursue my application for employment with the St. Luke’s Medical Center,
I am hereby tendering this Waiver and Acknowledgment in the following terms:

1. I am fully aware of the nature of the position I am applying for and acknowledge the risks and dangers related
thereto considering my health condition;

2. Should the Medical Center consider my application for employment, I shall undertake and comply with all
recommendations by the Associates’ Health Clinic in one month (upon signature of this document) for the control
of my pre-existing health condition;

3. I hereby waive and hold the St. Luke’s Medical Center free and blameless from any liability ordinarily related
to my pre-existing health conditions and other complications arising from said conditions, including but is not
limited to, hospitalization, medication and other benefits. This waiver shall be effective regardless of any change of
employment status and is to be considered distinct from the normal benefits package offered by the Medical
Center to its employees of similar employment status;

4. I voluntarily agree to be separated from the St. Luke’s Medical Center should my health condition deteriorate
due to the progressive nature of my pre-existing illness;

5. As a consequence of this Waiver and Acknowledgment, I shall be personally responsible and shall bear all
necessary expenses related to the treatment and maintenance of my pre-existing health condition, which include
but is not limited to:

A. All medicines related to treatment and complications of any medical findings;

B. Confinement diagnosed as, or diagnoses related to any medical findings;

C. Diagnostic procedures related to any medical findings.

6. That in the event that the St. Luke’s Medical Center accepts my Application for Employment, I acknowledge
the same as purely an act of magnanimity and that the consideration the Medical Center have extended may be
withdrawn unilaterally.

My signature affixed below is proof that I fully understood and execute this Waiver and Acknowledgment freely
and voluntarily.

(NAME OF APPLICANT)
SIGNATURE OVER PRINTED NAME
 PRE-EMPLOYMENT MEDICAL HISTORY FORM

Please complete all needed information and answer each question on this form. Kindly give full details if you
are declaring an existing or previous medical condition. All information provided shall be treated as strictly
confidential.

I. PERSONAL DETAILS
Position Applied for: Name of Applicant: Height:
Weight:

II. FAMILY HISTORY

Please describe the medical conditions of your relatives below. Indicate their diseases, if any (e.g., cancer,
alcoholism, heart disease, high cholesterol, kidney disease, high blood pressure, asthma, mental health
problem or disability, etc.)
 Father
 Mother
 Sister(s)
 Brother(s)
 Grandfather(s)
 Grandmother(s)

III. OCCUPATIONAL HISTORY

1. Has your employment ever been terminated on the grounds of ill health?  YES  NO

2. Approximately how many days/weeks sickness absence did you have?

In the last twelve (12) months __________________ In the twelve (12) months prior to that
________________

IV. MEDICAL HISTORY YES NO

1. Do you smoke cigarettes?  
If yes, how may sticks a day?
2. Do you drink liquor/alcohol?
If yes, how many units of alcohol do you drink weekly?  
________________________
3. Are you currently taking any prescribed medicine?
If yes, please give details/reason:  
___________________________________________
4. Are you currently under the care of a Doctor or other medical
professional?  

5. Are you currently suffering or have suffered from any of the illnesses listed below? (Please put a check
mark on the appropriate box. If your answer is yes, please give details and dates, as necessary).
YES NO DETAILS DATE(S)
 Frequent or severe
 
headaches/migraine
 Dizzy spells, fainting, or blackouts  
 Epilepsy or seizures  
 Eye trouble or vision problems  
 Any neurological problem  
 Tooth or gum problems  
 Hearing problems  
 Other ear, nose, throat problems  
 Hay fever or allergies  
 Asthma, wheezing or chronic cough  
 Trouble catching your breath  
 Heart murmur or heart problems  
 Rheumatic fever  
 Stomach, liver or intestinal problems  
 Jaundice or hepatitis  
 Bowel or bladder problems  
 Kidney trouble, stone, blood in urine  
 Sugar or protein in urine  
 Diabetes  
 Arthritis or joint pains  
 Joint or bone deformity or fracture  
 Malaria or other tropical disease  
 Any skin problems  
 Tuberculosis (TB) or exposure to
 
persons with TB
 Anemia  
 High blood pressure  
 Lung disease  
 Serious accident  
 Sadness or withdrawal  
 Trouble in sleeping  
 Severe stress reaction  
 Depression or anxiety problems  
 Speech delay or other speech problems  
 Behavioral or discipline problems  
 Other illnesses  

V. HOSPITALIZATION/OPERATIONS/MEDICAL EVACUATIONS (include all medical and psychiatric illnesses)

Date (MM/DD/YY) Illness/Operation Name of Hospital City

Other conditions that could have an impact on your ability to fulfill your duties and responsibilities:

I hereby declare that all the information stated herein are true and complete to the best of my knowledge.
I understand that if, at a later date, it is discovered that I have knowingly withheld personal and medical
information, disciplinary action may be taken against me, which may include dismissal.

_________________________________
Name & Signature of Applicant