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