JOINT DOH-POEA-MARINA CONSULTATIVE COMMITEE SB no.

REFERRAL SLIP FOR MEDICAL EXAMINATION PP no. EC7336057

Bday. 10/09/1989
PHILIPPINES

Serial No.
Date October 26, 2020
Name of Employer GLOBAL PETROPROJECTS SERVICES AG

Country of Destination INDONESIA

I. WORKER: DE CASTRO, RON RON DE CHAVEZ 31 yrs., Male

X / Female
Lastname Firstname Middle Name
SAN ROQUE BAUAN BATANGAS PHILIPPINES 4201
Home Address ( Street, Municipality )
SINGLE STRUCTURAL WELDER
Civil Status Position Applied for

INSTRUCTION TO WORKER
1. You are scheduled for Medical Examination on October 27, 2020
at PHYSICIANS DIAGNOSTIC CLINIC – UN AVE ERMITA MANILA PHILIPPINES
( Name and Address of Medical Clinic )
2. Bring the following:
2.1 Two (2) clean boiled bottles. One must contain a thumbsized sample of your stool and the other empty.
LABEL THE TWO BOTTLES WITH YOUR NAME.
2.2 Four (4) copies of 2 x 2 pictures.

3. The examination to be performed and the rates to be paid are indicated at the back of this page.
PLEASE ASK FOR AN OFFICIAL RECEIPT FOR ANY PAYMENT GIVEN.

4. Non-compliance of the above instruction may caused delay of the processing of your application.

I HAVE READ, UNDERSTOOD AND AGREED TO COMPLY WITH THE ABOVE REQUIREMENTS

Date Signature

II. MEDICAL CLINIC

Date of last medical examination
REFERRED TO: PHYSICIANS DIAGNOSTIC CLINIC – UN AVE ERMITA MANILA PHILIPPINES
Name & Address of Accredited Medical Clinic / Hospital

Please conduct the following medical examinations:

GPS PROTOCOL C LANDBASED + HEPA A, B, C TEST, HIV TEST, DRUG AND
ALCOHOL TEST, SPIROMETRY TEST

Manpower Resources of Asia, Inc. 1179 Don Chino Roces Ave. corner Bagtikan St., Makati City
III. AGENCY / COMPANY :
Name and Address

Mr. Christopher Dino C. Dumatol

Printed Name and Signature
of Authorized Official
President
Designation