LIST OF AFFECTED WORKERS DUE TO COVID-1

Instruction: If necessary, use additional sheets following the same format.

CONSENT NOTICE: By accomplishing this form, you agree that the information submitted shall be used solely for purposes of processing C
We may likewise disclose your personal information to the extent that we are required to do so by the Data Privacy Act of 2012. As a genera
we have attained the purpose by which we collect them. Under the foregoing circumstances and to the extent permissible by applicable law,
disclosure and retention of your information.

Profile of Affected Workers

* Mandatory fields to be accomplished by the company representative for COVID-19 AMP applications.

NO EMPLOYEE'S LAST NAME* EMPLOYEE'S FIRST EMPLOYEE'S MIDDLE EMPLOYEE'S ADDRESS*

NAME* NAME*
RKERS DUE TO COVID-19

ed solely for purposes of processing CAMP applications pursuant to Labor Advisory No. 09-2020.
Data Privacy Act of 2012. As a general rule, we may only keep your information until such time that
e extent permissible by applicable law, you agree not to take any action against the DOLE for the

EMPLOYMENT SALARY*
EMPLOYEE'S CONTACT AGE* SEX* DESIGNATION* STATUS* (Indicate whether
#* (regular, per hour, per day or
contractual, etc.) per month)