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DEPARTMENTOFLABORANDEMPLOYMENT CHECKUSTOFDOCUMENTARY DOLE-BWC-AF-CHK-PC

JBureauof WorkingConditions A REQUIREMENTS ON ACCREDITAlON Revision Code: 0803-0Intramuros, Manila

OF OSH PRACTITIONER/CONSULTANT Page 1 of 1

Preparedby: OHSD-SPIS Approvedby: DirectorTERESITAR.MANZALA,CESOIII Effectivity Date: August 2003

INSTRUCTION: To the applicant -Pleasefasten all attachments/documents neatly in a long plain folder and arranged according to thefollowing order enumerated below. Application may be submitted directly to BWe or to concerned R.O. Documents submitted must be signed inall pages.To DOLE receiving personnel. Please (V) or (X) mark in the appropriate column below when receiving application. Appticatlon withIncomplete documents shall be returned to the applicant together with this checklist indicating requirements for compliance.

Name of Applicant:as:U OSHPractitioner U OSHConsultant

DOCUMENTARY REQUIREMENTS CHECKLISTSubmitted Remarks

New Applicants:YES NO

1. Two (2) copies of duly accomplished Application Form (DOLE-BWC-AF-PCN-Al)with 2 copies most recent 1 x 1 ID picture signed at the back. (red background for SP,blue backQroundfor SC).

2. Original Certificate of Employment indicating name, position and date of appointment atDresentDositionusina the offidalletterhead of the COmDany.

3. Original of actual Duties and Responsibilitiesat present position, signed by immediatesupervisor and Personnel Manager or authorized offidal of the company, using letterheadof the company.

4. Photocopyof certificate of employment from previous employer/s indicatingposition(s) anddate(s) of appointment (if any and necessary in support of actual experience on OSH). Maysubmit actual functionsand Droofof accomDlishmentsduly certified by the emDloyer.

5. Photocopyof certificateof completionof the BureauPrescribedCourse (4o-hr or 8o-hr)onOccuDationalSafetYand Health issued by accredited STO.

6. Photocopy of certificate of attendance/partidpation on other OSH related trainings /seminars/activities.

7. Photocopyof CollegeDiplomaor Transcript of Records and Board ExamCertificateor PRCUcense(ifany). .

8. Proof/s of accomplishment or participation in OSH_ accident reports_ safety inspection/audit reports_ HSC committee report _ aSH program prepared/ implemented_ Other reports prepared by the applicant, please specify

Renewal of Accreditation:1. Two (2) copies of duly accomplished Application Form (DOLE-BWC-AF-PCN-A2)

with 2 copies most recent 1 x 1 ID picture signed at the back. (red background for SP,blue backaround for sct

2. Summary of Applicant's Accomplishments as OSH Practitioner / Consultant related to aSHsigned by the employer and supervisor using official letterhead of the company. Consultantwith more than one client- establishments shall submit an accomplishment report certifiedby the client's.

4. Photocopyof Certificate of Accreditation (last issued).

5. Photocopyof other aSH related trainings/seminars attended after last renewal of at least 16hours per year or 48 hours of trainings for 3 years, earned from DOLErecognized/accreditedSTO/institutions authorized by law.

6. Proof/s of accomplishment or participation in OSH_ accident reports_ safety inspectionreports_ safety audit reports_ HSC committee report _ aSH program prepared/ Implemented_ Other reports prepared by the applicant, please specify

When There Is if Chifnae of EmDlover/Dosition

7. OriginalCertificateof Employmentindicatingname, positionand date of appointment at presentDOsitionusina offidal letterhead of the company.

8. Originalof actual Dutiesand Responsibilitiesat present position, usingoffidalletterhead of the company,signed by immediatesupervisor and Personnel Manaaer or authorized officialof the comcanv.

INITIAL EVALUATION/ REMARKS: Note: Originals will be required for_ Complete documents submitted, signed In all pages. presentationduring interviewif new_ With incomplete documents, for compliance of the above statedapplicant; during filing of application ifdefidendes with mark"x:'.

_ Forinterviewon at . pleasecall5273483or 5275496.renewal._ Othe, specify

Checked / Receivedby: Date/Time:

__ DEPARTMENTOF LABORAND EMPLOYME~?~\. Bureauof WorIdngConditions L'"'.!:A. Occupational Health and Safety Division lIT

DOLE-BWCAF-PCN-AlRevision Code: 0803-0

Page 1 of 3Instructions:Fill in all the data needed. Use block/printed letters or use a typewriter. Write N.A. if the blanks are notApplicable. Please sign in all pages of the form.

I would like to apply for Accreditation as: o aSH Consultant

o aSH Practitioner

1. PROFILELast ,Na~e Mlddli!NameFirst Name Sex: <:b£ilStatus:

U Single

o Married

Otizenshlp:

Religion:

OM o F

City Address (Number & Street, Town/City, Province, Zip Code) Date of Birth:

HDme/Provincial Address

Height:

Weight:

Blood Type:

SSS/GSIS No.

TIN No. :

Please attach your1" x 1" pictureSC: blue backgroundSP: red background

2 COPIESsigned at the back

o Widower/Widow

o Separated

PRC No.(if any):

Home No.:

Cellular Phone No (if any):

Co. Tel No.:

Business Address

Nature of Business I Specific Productl Type of Service: E-mail: FaxNo.:

PSIC Code:

o Hazardous 0 Non-hazardous

Region:

Employment Size:MALE:_ FEMALE:_ TOTAL: _Workplace:

GEO Code: Zip Code:

Degree/units Eamed Inclusive dates Awards/ Honors

Type of Professional Ucense received:PRC Ucense NO.: Date Issued: Validitv:

To be accomplished in duplicate Note: This form isNOT FOR SALE. It may be reproduced24

To be accomplished in duplicate25

Note: This form is NOT FOR SALE. It may be reproduced

Jt:. DEPAJrnoIENTOFlABORANDEMPlOYMENTA DOLE-BWC<1'. BureauofWcrlcJngConditions

OccupationalHealthandSafetyDivIsion r- OSH PRACTITIONER/CONSULTANT AF-PCN-AlAPPLICATION FORM RevisionCode: 0803-0

(New Applicant) Page 2 of 3

4. aSH RELATED TRAININGS' SEMINARS ATTENDED ( As Participant) -, (Use additionalsheet if necessary)Please attachphotocopy of certificate. Originalcopies of certificatesto be presented to authorized DOLEstaff for

certification.

No. of Conducted by VenueTitle Time' Duration Hours

(Start from recent to previous) From To

5. aSH RELATED LECTURES' SEMINARS fTRAININGS CONDUCTED ( As Resource Speaker) (Useadditionalsheet ifnecessary ) Please attach Dhotocopv of certificate/recoanition received.

o. of Ct>f\u<;:,{ iJ'fV€(t{{€

TitlefTopic Time' Duration Hours(Start from recent to previous) From To

6. aSH SKILLS' EXPERTISE' SPECIALIZATION ACQUIRED (Useadditionalsheetif necessary)

Trade' Occupation Field of Expertise Brief DescriptionYears of

EXDerience

7. aSH AWARDS' ACHIEVEMENTS 'RECOGNITION RECEIVED (Use additional sheet if necessary). Attachphotocopy of certificate of award/recognition

Title Issued by Date Issued

To be accomplished in duplicate26

Note: This form is NOT FOR SALE. It may he reproduced

DEPARTMENT OF lABOR AND EMPI.OYMOSH PRACTITIONER/CONSULTANT DOLE-BWC

Bu"eauof Wor1dngCOnditions Ii:OcOJpatIonal_Ith and Safety Division APPLICATIONFORM AF-PCN-Al

(New Applicant) Revision Code: 0803-0

Page3 of 3

8. OSH EXAMINATIONS' ELIGIBILITIES PASSED (if any) (Useadditionalsheetif necessary).PleaseattachDhotocoDvof ID, license or certification

Title Year Taken Given bv Ratina

9. MEMBERSHIPS' AFFILIATIONS RELATED TO OSH

OrQanization'Institution' AQency DesiQnation, Position Validitv

10. CHARACTER REFERENCES (give at least 3)

Name Position I Occupation Companv I Address Contact Numberls

Do you have any pending a) administrative case DYes D No b) criminal case? DYes D No

If you have any, give details of the offense

Have you been convicted of any crime or violation of any law, decree, ordinance or regulations by any court ortribunal?

DYes D No If yes, give details

Have you ever been convicted of any administrative offense? DYes D No

If your answer is "YES", give details of the offense

Have you ever been retired, forced to resign or dropped from employment in the public and private sector?

DYes D No If yes, give reasons

I certify that the information stated above are true and correct.RIGTH THUMB

Date: MARKSIGNATURE