Appendix 80

AUTHORIZATION FORM FOR QUERYING THE BANGKO SENTRAL WATCHLIST FILES FOR SCREENING APPLICANTS AND CONFIRMING APPOINTMENTS OF DIRECTORS AND OFFICIALS
(Appendix to Section 138 on Watchlisting)

A U T H O R I Z A T I O N

I, _________________________________ after being sworn in accordance with law, do hereby authorize the following, pursuant to the provisions of Section 138 on confidentiality:

a) (Name of Bank), to conduct a background investigation on myself relative to my application for or appointment to the position of (position) in (Name of Bank) which include, among others, inquiring from the Watchlist Files of the Bangko Sentral; and

b) The Bangko Sentral to disclose its findings pertinent to the aforementioned inquiry on the said watchlist files to (Name of Bank).

With the above authorization, I hereby waive my right to the confidentiality of the information that will be obtained as a result of the said inquiry, provided that disclosure of said information will be limited for the purpose of ascertaining my qualification or non-qualification for the said position.

IN WITNESS WHEREOF, I have hereunto set my hand this

____________________________
(Signature Over Printed Name)

SIGNED IN THE PRESENCE OF:

Witness Witness

____________________________________________________________________________

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES )
PROVINCE/CITY OF ) S.S

BEFORE ME, this _______ day of ______________ 200___ in _______________personally appeared the following person:

Name Comm. Tax
Cert. No.
Date of Issue Place of Issue

known to me to be the same person who executed the foregoing instrument and he acknowledged to me to be the same person who executed the foregoing instrument and he acknowledged to me that the same is his free act and deed.

This instrument, consisting of two (2) pages, including the page on which this acknowledgment is written, has been signed on the left margin of each and every page thereof by, and his witnesses, and sealed with my notarial seal.

IN WITNESS WHEREOF, I have hereunto set my hand, the day, year and place above written.

Notary Public

Doc. No. : ______________
Page No.: ______________
Book No.: ______________
Series of __________.

(Circular No. 969 dated 22 August 2017)