Deparnantof aber and Elona APPLICATION FORM A Stellar wonme ceriens FOR ACCREDITATION OF OSH ArO2le ‘TRAINING/CONSULTING ORGANIZATION | [ov %<°' ‘structions: — Please acomplsh Completav and aliach the required documents, Refer to cheakist of requirements Vaied tel for attachments (new/renewal) and_mark (¥) in the lft hand portion ll documents submited Pursuant to requirement of D. 0. 16, series 2001, We would lke to apply for an accreditation as Safety Training Organization (C] New [] Renewal Safety Consulting Organization 1. PROFILE - Please attach certified true copies of Business Reoistration with SEC, BIR and DOLE, and Mayor's Permit to operate Name of Crganzaon 1 Type of Organization [i] Government CJ Private C1] Semtgovernment _ ____| Oiner, please specty Company Adress Sec. Reg, No ] Date Registered ‘Name of Top Company Head Havers PermitNo.s | Date of Issuance: ‘iia Te Designaton ~~ 1 BIR Regisration ae Tei Np. ~ - IN No. ore - Fax No. - Registered with DOLE?: Yes. No |" 7 —_ | Date Registered Ena Adress Employment size [Mate FEMALE: TOTAL (This COLUMN is to be accomplished by DOLE) (CHECKLIST OF REQUIREMENTS Remarks For New Applicant Duly accomplished application form: ‘Certified true copy of Business Registration with SEG Certified true copy of Mayor's Permit) License to operate Certified true copy of Registration with DOLE Regional Office Corte true copy of Registration with BIR Contract of Agreement with Consultant /Resource Person Resume of Consultai/Resource Person Photocopy of Contract of Agreement with Venue_(W applicable) ~ For STO applicant only Photocopy of contract of agreement with supplier (IF applicable Copy of Training Manual (For STO applicant only) _ Copy of Training Syllabus on BWC prescribed course on OSH (For STO applicant only ‘Copy of Cerificate of Completion (For STO applicant only For Renewal: ‘Duly accomplished application form 2. Calendar of training or services and other OSH related evils 3._Photocopy of latest certificate of accretion ‘Summary of Annual Accompishment- Report_on talnings conducted for STO ( Fornr ‘and consultancy services_provied for SCO (Form. 5._Updated resume of trainers (for STO) o consultants (for SCO) 6._Evaluation of participants/cients on_tralning or services provided. Evaluator’s Remark Received by: (Siana Position: Region. Date/Tima:Deparment of Labor and Emeloyment A _eUREAL OF woRKNG CONDITIONS ‘occupational Health and Safty Dv. APPLICATION FORM FOR ACCREDITATION OF OSH TRAINING/CONSULTING ORGANIZATION ‘AF-02 Rev. Code: 0403-0, Page 2of 3 2. HISTORY AND BACKGROUT ‘organization IND — Please provide one or two paragraph describing the history and background of your Staff_- please attach your organizational chart ‘Name of Postion Taicatoral Background | Type of Employment] — Tf coniraetal (pect Adminicrative/ Support (Reguiar, Project Based, | period of contact) ieaneeul oe Contractual) , L = agreements with them. 4, Technical - Use addtional sheet i necessary. ‘Please attach resume of technical staff/resource speakers and contract of Highest Educational ‘Attainment Field of expertise/specialization/ ‘competence Tf aceredited as OSH Professional, specty Accreditation No. and Valiity | — ‘Name of Technical Staff -— 5, LIST OF FACILITIES/ EQUIPMENT ~ Use additional sheet ifnecessary For Safety Training Organization- Please attach contract of agreement with venue if no availabe training room office Facilities/Equipment Number ‘Capacity (How many | can be accommodated ‘Office Faclities/Equipment | Number/Unit le at one time? _ Meeting Room Set of Computer & Printer Library ‘Telephone Receiving Area Fax Machin = ‘Training Room “Table & Chairs - Others, Please specify ‘Others, please specify U‘Deparment of Labor and Employment] APPLICATION FORM FOR ACCREDITATION OF | AF-02 BREAN OF WORKING CONETTIONS \TION | Rev. Coe: 04030 f Ba 220 oF WORE CONETICNS | OSH TRAINING / CONSULTING ORGANIZATIOI fen 6. OSH Information - What OSH information are available in you organization? (Books, Journals, Database, etc. = Please specity/ describe, add additional sheet if necessary Tite ‘To be filled-up by Safety Training Organization Applicant 7. Training Equipment/Materials_- Type of Training Equipment/Materials ian get _ (i availabe TB; for power poi reser || Overhead projectors (OHP) poate proetors Dal areas ‘VS VeDIBVD players ‘Other, please describe 8, List of Training Courses Offered Please enclose satus or outine of BWC prescribed Training on OSH (speciving Date/Time, Topic, Objective, Methodology and Resource Speakers), Copy of Training Manual, evaluation forms for trainers and ‘course program, and_ certificate of completion. = i we Target Prerequete | international/ | tany ‘National To be filled up by Safety Consulting Organization 9. TYPE OF OSH Consultancy - Alesse atach Ist of avalable equpment necessary inthe conduct of type of OSH consultancy services provided. Attach also list of clients (if any) [ (1 OH Satety Program Development and Implementation ‘Occupational Heath 1 ose safety auct/evaluation Industrial Hygiene Occupational Safety Management System Work Environment Measurement A In-lant Safety Inspection | OF Work Accident Investigation Fire Prevention, Protection and Control Other, Please specify Risk Assessment 1 certify that the information stated above are true and correct. RIGTH THUMB Date: MARK. ‘SIGNATURE