CONSENT FORM
PERSONAL HISTORY STATEMENT (PHS)
By signing this consent form. I (as “Data Subject”) grant my free, voluntary and unconditional
consent to the collection and processing of all Personal Data (as defined below) to the information
database system of the Research and Production Division {“RPD") and/or any of its authorized
representative/s as Personal Information Controller (PIC), by whatever means in accordance with
Republic Act (R.A.) 10173, otherwise known as the “Data Privacy Act of 2012” of the Republic of the
Philippines, including its Implementing Rules and Regulations (IRR).
I understand that my “Personal Data" means any information, whether recorded in a material form
or not, (a) from which the identity of an individual is apparent or can be reasonably and directly
ascertained by the entity holding the information, or when put together with other information would
directly and certainly identify an individual, (b) about an individual’s race, ethnic origin, marital
status, age, color, gender, health, education and religious and/or political affiliations, (c) referring to
any proceeding for any offense committed or alleged to have been committed by such individual, the
disposal of such proceedings, or the sentence of any court in such proceedings, and (d) issued by
government agencies peculiar to an individual which includes, but not limited to, social security
numbers and licenses.
I am fully aware that the RPD shall be responsible for facilitating, which include among others, the
collection, processing, reproduction, and dissemination of the contents of the PHS, with appropriate
confidentiality. I hereby acknowledge that I have been provided with the written notification below on
my rights as a Data Subject (each, a “Right”, collectively, the “Rights”) in accordance with the
RA10173 or the Data Privacy Act of 2012, to wit: (a) to be informed whether Information and/or
Personal Data is being or has been processed; (b) to request for amendment/s to correct any
Information and/or Personal Data relating to the Data Subject which is inaccurate; (c) to object to the
processing of the Information and/or Personal Data in case of changes or amendments to the
Information and/or Personal Data supplied or declared to the Data Subject; or (d) to be provided
hardcopies of the completely filled-out PHS form.
I acknowledge, further, that if I was to exercise any of the Rights enumerated above, RPD reserves the
right to re-evaluate the Information and/or Personal Data that has been collected and processed.
I have read and understood the above and hereby consent to, agree on, accept and acknowledge these
terms of consent for myself/ourselves and/or as agent/s for and on behalf of the principal. I represent
by signing below:
Signature over Printed Name
Signed in ____________________on_______________
.. Notary Public Signature
