Ofw Information Sheet - Philippine Overseas Employment Administration
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1LASTEST PAYMENT:
DO NOT WRITE ON THIS SPACE
DATE: ______
(For POEA, OWWA, Philhealth Use Only)
1. OWWA
CG No:
__________________________
MEMBERSHIP: _________________
RFP No:
__________________________
Assessment No:
____________________
PHILIPPINE OVERSEAS EMPLOYMENT ADMINISTRATION
2. PHILHEALTH/
Assessed Amount :
OVERSEAS WORKERS WELFARE ADMINISTRATION
MEDICARE: ___________________
POEA:
_________________________
PHILIPPINE HEALTH INSURANCE CORPORATION
OWWA: _________________________
PHILHEALTH: ___________________
OFW E-Card / ID No:
FM-POEA O2-GP-07
Effectivity date : April 8, 2005
OFW INFORMATION SHEET
)
PERSONAL DATA
Change/s (if any
Name _
________________________________ _______________________________ ______________________________
___________________________________
Family Name (Apelyido)
First Name (Pangalan)
Middle Name (G. Apelyido)
___________________________________
Address in the Phils (Tirahan):
_________________________________________________________________________
___________________________________
__________________________________
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:
______________________________________
_____________________________________________
Legal Beneficiaries (Mga tatanggap ng benepisyo sa OWWA) :
Name
Relationship
Address
________________________________________________________
________________________
________________________________________________________
________________________________________________________
________________________
________________________________________________________
________________________________________________________
________________________
________________________________________________________
ALLOTTEE (Itinalaga na padadalhan ng bahagi ng sahod ng OFW):
__________________________________________________________________
________________________________________________________________________
C
CONTRACT PARTICULARS OF OFW
hange/s (if any)
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 /
Approval of Authorized Agency
Thumbmark
Representative ( if agency-hired)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(T
o 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
Date of Birth
to dependent/s
(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
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