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OFW Info Sheet
DOLE information sheet of overseas filipino workers
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: LASTEST PAYMENT:
DO NOT WRITE ON THIS SPACE
DATE: ______
(For POEA, OWWA, Philhealth Use Only)
1. OWWA
MEMBERSHIP: _________________
CG No:
__________________________
RFP No: __________________________
Assessment No: ____________________
Assessed Amount :
POEA:
_________________________
OWWA: _________________________
PHILHEALTH: ___________________
2. PHILHEALTH/
MEDICARE: ___________________
PHILIPPINE OVERSEAS EMPLOYMENT ADMINISTRATION
OVERSEAS WORKERS WELFARE ADMINISTRATION
PHILIPPINE HEALTH INSURANCE CORPORATION
OFW E-Card / ID No:
FM-POEA O2-GP-07
Effectivity date : April 8, 2005
OFW INFORMATION SHEET
Change/s (if any)
PERSONAL DATA
Name _________________________________ _______________________________ ______________________________
___________________________________
___________________________________
___________________________________
__________________________________
Birth date: ____ / ____ / _____ Sex:
M
F
Civil Status:
Single
Widowed
__________________________________
MM DD YYYY
__________________________________
Married
Separated
__________________________________
Passport No: ___________________________
Highest Educational Attainment: __________________________
__________________________________
Name of Spouse (if married): ______________________________________ Mother’s Full Maiden Name: _____________________________________________
Family Name (Apelyido)
First Name (Pangalan)
Middle Name (G. Apelyido)
Address in the Phils (Tirahan): _________________________________________________________________________
Legal Beneficiaries (Mga tatanggap ng benepisyo sa OWWA) :
Name
________________________________________________________
________________________________________________________
________________________________________________________
Relationship
Address
________________________
________________________
________________________
________________________________________________________
________________________________________________________
________________________________________________________
ALLOTTEE (Itinalaga na padadalhan ng bahagi ng sahod ng OFW):
__________________________________________________________________
________________________________________________________________________
Change/s (if any)
CONTRACT PARTICULARS OF OFW
_________________________________
Name of Principal / Company / Employer: ________________________________________________________________
Address: ______________________________________________________________________________________________
_________________________________
Jobsite/Country of Destination: _____________________________________
Tel No: ______________________
_________________________________
Position of OFW: ___________________________________
Fax No / Email address: ______________________
_________________________________
Contract Duration ___________ months
Monthly Salary: ___________________
Currency: _____________
_________________________________
Last date of arrival of vacationing worker in the Phils: _________________________________________________
_________________________________
Date of scheduled departure / Return of OFW to the jobsite: ___________________________________________
_________________________________
Name of Agency (if applicable): _______________________________________________________________________________________________________________
___________________________________
Signature of Worker /
Thumbmark
__________________________________
Approval of Authorized Agency
Representative ( if agency-hired)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(To be filled in by OFW – for PHILHEALTH RECORD)
Name of Worker: _____________________________________________________________________________________________________________
Family Name (Apelyido)
First Name (Pangalan)
Middle Name (G. Apelyido)
Address in the Philippines (Tirahan) :_____________________________________________________________ Tel No: ______________
Date of Birth:
_____ / _____ / ________
Birthplace: ____________________________________________
MM
DD
YYYY
Sex:
M
F
Civil Status:
Single
Married
Widowed
Separated
Dependents (Mga makikinabang):
20 years old and below for child/ren, 60 years old and above for parents, and Unemployed spouse.
Name of Children/Parent/Spouse
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Sex
______
______
______
______
______
______
______
Relationship of OFW
to dependent/s
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Date of Birth
(mm/dd/yyyy)
__________________
__________________
__________________
__________________
__________________
__________________
__________________
I hereby certify that the above statements are true and correct. (Ako ay nagpapatunay na ang nasa itaas na pahayag ay totoo at tama).
_________________________________
Signature of Worker
