X OSH Practitioner
1. PROFILE
Last Name First Name Middle Name Sex: Civil Status:
Valdez Jesus Baradas Single Widower/Widow
X
M F
X Married Separated
City Address (Number & Street, Town/City, Province, Zip Code) Date of Birth: Aug 18 1988 Citizenship: Filipino
Block 55 Lot 5 San Ramon Housing Canlubang, Calamba City,
Height: 170 cm Religion: Roman Catholic
Laguna 4028
Home/Provincial Address Weight: 80 Kg TIN No. : PRC No.(if any):
Same as City Adress Blood Type: A+ 0037117
Business Address SSS/GSIS No. Cellular Phone No (if any):
09202070211
Sinopec Branch Office Jubail City Eastern Province KSA
Home No.: Co. Tel No.:
+966-3-8879065
Nature of Business / Specific Product/ Type of Service : E-mail: Fax No.:
Petrochemical / Construction / Oil and Gas valdezjesusb.081888@yahoo.com +966-3-8879067
Workplace: Employment Size:
Hazardous Non-hazardous 5000+ FEMALE: _____ TOTAL : _____
MALE: ______ 5000+
X
2. EDUCATIONAL ATTAINMENT - indicate only tertiary education: Masteral, doctoral. Please attach
photocopy of diploma /transcript of records .
Degree/units Earned School / Address Inclusive dates Awards/ Honors
(Last attended)
B.S. Electrical Engineering Polytechnic University of the Philippines Jun 2005 - May 2010 N/A
3. WORK EXPERIENCE (Use additional sheet if necessary). Please attach original certificate of employment and job
description duly certified by the Personnel Manager/ employer/or authorized company official YEARS OF OSH
using official company letter head; and proof of practice (safety report/programs prepared/implemented). 5+ EXPERIENCE
Position Company
Inclusive Dates Length Status of
(From recent to present)
From To of service Appointment
HSE Supervisor Dec 2011 Present 5+ years Regular Employee Sinopec Engineering Group
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To be accomplished in duplicate Note: This form is NOT FOR SALE. It may be reproduced
DEPARTMENT OF LABOR AND EMPLOYMENT
Bureau of Working Conditions
DOLE-BWC
Occupational Health and Safety Division OSH PRACTITIONER/CONSULTANT AF-PCN-A1
APPLICATION FORM Revision Code: 0803-0
(New Applicant) Page 2 of 3
4. OSH RELATED TRAININGS / SEMINARS ATTENDED ( As Participant ) -. ( Use additional sheet if necessary)
Please attach photocopy of certificate. Original copies of certificates to be presented to authorized DOLE staff for
certification.
On Separate Page
Years of
Trade / Occupation Field of Expertise Brief Description
Experience
HSE Supervisor Petrochem/Cons/Oil/Gas Construction of Petrochemical and More than 5 years
Oil and Gas Complex
7. OSH AWARDS / ACHIEVEMENTS /RECOGNITION RECEIVED (Use additional sheet if necessary). Attach
photocopy of certificate of award/recognition
25
To be accomplished in duplicate Note: This form is NOT FOR SALE. It may be reproduced
DEPARTMENT OF LABOR AND EMPLOYMENT
Bureau of Working Conditions OSH PRACTITIONER/CONSULTANT DOLE-BWC
Occupational Health and Safety Division APPLICATION FORM AF-PCN-A1
(New Applicant) Revision Code: 0803-0
Page 3 of 3
8. OSH EXAMINATIONS / ELIGIBILITIES PASSED (if any) (Use additional sheet if necessary). Please attach
photocopy of ID, license or certification
Title Year Taken Given by Rating
Joselito Acosta HSE Manager Saudi Aramco Dow Petrochem Complex +63 995 9880 828
Mukhtiar Ahmed Safety Officer Sinopec Engineering Group +966 595 093 052
Do you have any pending a) administrative case Yes X No b) criminal case? Yes X No
Have you been convicted of any crime or violation of any law, decree, ordinance or regulations by any court or
tribunal?
Have you ever been retired, forced to resign or dropped from employment in the public and private sector?
I certify that the information stated above are true and correct.
RIGTH THUMB
________________________ Date: _____________ MARK
SIGNATURE
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To be accomplished in duplicate Note: This form is NOT FOR SALE. It may be reproduced