Boerne HEOR MD ROT ‘OSH PRACTITIONER) | DOLE-BWC Please attach your FD crn tain nd Sey aN CONSULTANT AF-PCN-AL ees) ‘30: blue bacxground APPLICATION FORM | Revision Code: 0003-0 | $& Mus packaroun (New /Renewal Page 1 of 3 ‘2.COPIES ‘signed at the back Fil in all the data needed. Use block/printed letters or use a typewriter. White N.A. I the blanks are not _appleable. Please sign in all pages of the form. | would like to. apply for accreditation as: ‘Accreditation No: (© OSHCONSULTANT (] OSH PRACTITIONER Date accredited: Date of last renewal: Valigity: 1. PROFILE [tase Name Fist Name Widaie Name Bee Status Single C1 widowerWidow | Gu GDFlg og | aries separated yaar (aber & Set, Toi, rane, Up Cade) | Date Bh ier: Taian | omer areas Tie 7 PRE Wairanys | | \ | Banas Rares : = ‘elle Prone Wo ari) | eal, | | Nature or wustnoesTSpecine Proaued Type of SontT Far Workin [Oy Hezardous [7] Nomhazardous FEMALE: _ TOTA. | | | Paie Coa ] eater Bip Codes 1 2, EDUCATIONAL ATTAINMENT - indicate only tertiary education: Masteral, doctoral. Please atiach photocopy of diploma transcript of records Degreelunts Eamed ‘School / Address Tholusive dates | Awards/ Honors (Last attended) ‘Type of Professional License received: PRC License N Date Issued Vakity: 3. WORK EXPERIENCE (Use additional sheet ifnecessary). Please attach original certificate of nt and job description duly certified by the Personnel Menager/ emoloyerior authorized company official ‘Total OSH Using official company letter head; and proof of practice (safely reportfrograms preparedsmplamented) EXPERIENCE pom Inclusive Dates | Length Status of coma (From recentto present) EST sro | of sevice | Appointment le c t ‘To be accomplished in duplicate Note: ‘This form is NOT FOR SALE. It may be reproduced@ Neg oie DOLE-BWC Cito Mat nd So on OSH PRACTITIONER/CONSULTANT | AF-PCN-A1 ‘APPLICATION FORM Revision Code: 0803-0 (New /Renewal) Page 2 of 3 4, OSH RELATED TRAININGS / SEMINARS ATTENDED ( As Participant ) ~.( Use additional sheet if nocessary) Please attach photocopy of certificate. Original copies of certificates to be presonted to authorized DOLE staff for catifcation. ; ee No. of Conducted by Venue Title Time / Duration | _ Hours | (Start from recent to previous) [ From | To | 5. OSH RELATED LECTURES / SEMINARS /TRAININGS CONDUCTED ( As Resource Speaker ) (Use ‘ational sheet if necessary ) Please attach of cortfcaterecogniion received. f T No.of |” Conducted by Venue | Title/Topic | Time /Duraton_| Hours (Start from recent to previous) [From | To 6. OSH SKILLS / EXPERTISE / SPECIALIZATION ACQUIRED (Use acltional sheet i necessary) Years of 7 Te Trade /Oscupation | _Field of Expertise Brief Description eames jf | i Es { 7. OSH AWARDS / ACHIEVEMENTS /RECOGNITION RECEIVED (Use adkitional sheet if necessary). Attach photocopy of certificate of awardrecognition [ Title Issued by Date Issued “To be accomplished in duplicate Note: ‘This form is NOT OR SALE. It may be reproduced@ ‘OSH PRACTITIONER/CONSULTANT | DOLE-BWC ‘APPLICATION FORM AF-PCN-A1 (New /Renewal) 8. OSH EXAMINATIONS / ELIGIBILITIES PASSED (if any) (Use acitional sheet if necessary). Please attach photocopy of 1D, license or certification Title Year Taken Given by Rating 9. MEMBERSHIPS / AFFILIATIONS RELATED TO OSH [organization / institution / Agency Designation / Position Valiity 10. CHARACTER REFERENCES ( give at least 3) a Name Position / Occupation ‘Company / Address Contec amber | i L Do you have any pending ) administrative case] Yes [No b)criminalcase? (Yes [] No Ifyou have any, give detalls ofthe offense. Have you been convicted of any crime or violation of any law, decree, ordinance or regulations by any court or ‘vibunal? 1 ves C No tyes, give detais Have you ever been convicted of any administrative offense? CI. yes Owe 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? D0 Yes] No ifyes, give reasons. | cently that the information stated above are true and correct. RIGTH THUMB Date: MARK ‘SIGNATURE ‘To be accomplished in duplicate [Note: This form is NOT FOR SALE. It may be reproduced