FM-POEA 02-GP-07 Effectivity Date: October 03, 2011 DATE:_____________________

BM EVALUATOR EVALUATION/ ENCODING ____________ ____________ TIME TIME RECEIVED RELEASED

DO NOT WRITE ON THIS SPACE (for POEA, OWWA, PhilHealth Use Only)

CG No:___________________________ RFP No:___________________________ Assessment No:_____________________ Assessed Amount:___________________ POEA: __________________ OWWA: __________________ PHILHEALTH:__________________ PAG-IBIG: __________________

THIS FORM IS NOT FOR SALE PHILIPPINE OVERSEAS EMPLOYMENT ADMINISTRATION

OVERSEAS WORKERS WELFARE ADMINISTRATION PHILIPPINE HEALTH INSURANCE CORPORATION

BALIK-MANGGAGAWA INFORMATION SHEET

Remarks _____________________________ _____________________________

Name of Spouse:

_____________________________

Worker’s Signature Over Printed Name

 

 

 

  PERSONAL DATA

Name: ______________________________ ______________________________ _______________________________ Family Name (Apelyido) First Name (Pangalan) Middle Name (G. Apelyido) Passport No:____________________________________ M F Birthdate: _______/_______/________ Civil Status: MM DD YYYY Single Widower Married Separated Address in the Phils. (Tirahan)__________________________________________________________________________________________ Telephone/Cellphone No. _______________________________________ Email Address:_________________________________________ Name of Spouse (if married):____________________________________ Mother’s Full Maiden Name:_____________________________

CONTRACT PARTICULARS OF OFW

Name of Company/Employer:__________________________________________________________________________________________

Address of Employer:_________________________________________________________________________________________________

Jobsite/Country of Destination:_______________________________ Tel. No./Fax No./Email address:_____________________________

Position of OFW:____________________________________________ Contract Duration:________________________________________

Salary:_____________________________________________________ Currency:_______________________________________________

Date of arrival:______________________________________________ Date of departure/Return of OFW to the jobsite:______________

______________________________________________ Worker’s Signature Over Printed Name

FOR BM GROUP/AGENCY Name of Agency:_________________________________________________________________________________________ ______________________________________________ Approval of Authorized Agency Representative OWWA Legal Beneficiaries (Mga tatanggap ng benepisyo) Name Relationship Address ____________________________________ __________________________ _____________________________________ _________________________________________ _____________________________ _________________________________________ PHILHEALTH PORTION TO BE FILLED OUT BY OFW

Name ______________________________ ______________________________ _______________________________ Family Name (Apelyido) First Name (Pangalan) Middle Name (G. Apelyido) Address in the Philippines (Tirahan): Email Address:_______________________________

___________________________________________________________________ _________________ ______________ _______________ Residential Address Barangay Municipality Province Date of Birth:____ / ____ / ________ Birthplace:________________________ SSS No._________________________ mm dd y y y y Complete Address of Destination (Foreign Country): _____________________________________ \ ________________________________ City Country Contract/Work Permit Expiry:________________________________________________________ Contract Duration:________________ Civil Status: Sex: Single Married Male Widower Separated Female Dependents (Mga Makikinabang): Children – 20 years olf and below: Parents – 60 years old and above, Unemployed Spouse. (Documents Required: Birth Certificate (Child & Parent); Spouse – Marriage Certificate, or Senior Citizens Card.

Name of Legal Dependent

Sex Relationship of OFW to

Dependent/s Date of Birth

(mm/dd/yyyy)

I hereby certify that the above statements are true and correct and that the above-named dependents have not been declared by my spouse/brother/sister.

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ISSUANCE OF OVERSEAS EMPLOYMENT CERTIFICATES POLO-OWWA in Riyadh and Alkhobar issue Overseas Employment Certificates (OECs) to workers going on vacation to the Philippines for their convenience. The OEC is required to be presented to international ports of exit in the Philippines as proof that the holder is a bonafide OFW. OEC holders are excempted from paying the travel tax and the airport terminal fee. The OEC has a 60-day validity.

In applying for the OEC, the worker has to present the following documents to POLO, namely:

a. copy of exit/re-entry visa, b. copy of passport, c. proof of employment such as certificate of employment or company ID issued by

the employer.

Cost of the OEC is Saudi Riyal 9.00.

Cost of OWWA Membership fee is Saudi Riyal 94.00

Cost of Pag-Ibig Membership update is Saudi Riyal 20.00

PHILHEALTH is NOT required.

IMPORTANT POLO CONTACT NUMBERS

Landlines: (01) 483-2201, (01) 483-2202, (01) 483-2203

(01) 483-2204 (fax number)

(01) 481-6448 (Filipino Workers’ Resource Center-Bahay Kalinga)

POLO Hotline : 00966-545917834

OFFICE HOURS

RIYADH: Saturdays to Wednesdays (8:00 am to 5:00 pm)

KHOBAR: Saturdays and Sundays (10:00 am to 4:00 pm)