DOLE-SENA FORM No.

1 Republic of the Philippines Date Filed

(Request for Assistance Form) Department of Labor and Employment
________________________________
(Name of Office)

SINGLE-ENTRY APPROACH (SENA)

(Per Department Order No. 107, Series of 2010)

Reference No.: SEAD-_________________________

Name of Requesting Party: Name of Responding Party:
(Pangalan) (Pangalan)
__________________________________________________ _____________________________________________
Pls. check () Male  Female  Pls. check () Male  Female 
Union  Company  Union  Company 
Nature of Business:_____________________________
Address: ______________________________________________
(Tirahan)__________________________________________
_________________________________________________ Total No. of Employees:

Tel. /Cel./Fax/E-mail:_________________________________ Male Female

__________________________________________________
Date of Employment: _______________________________
(Kailan napasok sa trabaho)
Years of Service: _______________________
(Taon sa Serbisyo)
Nature of work:
(Trabaho):_________________________________________
Contact Person: _________________________________
(Taong Kakausapin sa Kumpanya)
Position: _____________________________________
(Katungkulan)
Address:_________________________________________
_______________________________________________
Tel. /Cel./Fax/E-mail: ______________________________

CLAIMS/ISSUES RELIEF PRAYED FOR ACTION TAKEN

(Please check the appropriate box/es) (Ano ang gusto niyong solusyon sa reklamo (To be filled-out by SENA Desk Officer)
o problema?)
 Advise and Counseling
a) Money claims
 Payment of Money Claims  Set for Joint Conference on
Non-payment/underpayment
 Reinstatement _____________________
of:
 Cessation of ULP acts  Settlement agreement signed
1.  wage
 Restitution/Correction of on _____________________
2.  Overtime Pay
3.  Night-Shift Differential violations of Occupational Safety  Withdrawal by either or both
Pay and Health standards parties
4.  Service incentive leave  Conduct Certification Election  Referred to ________________
5.  Holiday pay  Conduct of Election of Union BY REASON OF:
6.  SSS Officers Failure of the parties to
7.  Philhealth  Audit/Examination of Union reach an agreement within
the 30-day mandatory
8.  PAG-IBIG Funds
 Others (Please Specify) conciliation-mediation period;
b) Unfair Labor Practice (ULP)
c)  Illegal Dismissal Failure of the requesting
d) Illegal Dismissal with Money party to appear in two (2)
Claims scheduled consecutive
e) Non-compliance with conferences despite due
Occupational Health and Safety notice.
Standards
f) Certification Election Dispute Pre-termination of the
proceedings with request of
g) Inter/Intra Union Dispute
issuance of Referral from
h) Cancellation of Union
________________________
Registration REMARKS:
i) Others (Please Specify)

______________________________
____________________________
Requesting Party’s Signature
SENA Desk Officer
(Signature over Printed Name)