OVERSEAS WORKERS WELFARE ADMINISTRATION

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“BALIK PINAS! BALIK HANAPBUHAY!” PROGRAM
INTAKE SHEET FORM
CONTROL NO:__________________ DATE FILED:_____________________
I. Datos Tungkol sa Aplikante/OFW

PANGALAN

(Last Name) (First Name) (Middle Name) (Suffix)

TIRAHAN

(Kumpletong Address)

Telepono/Cellphone/Facebook/Messenger

Kapanganakan (Birthdate)

Katayuang Sibil (Civil Status)

● (Please check on the box provided)

Ang Aplikante ay:

Land-based Sea-based

Displaced Dahilan: Gaano katagal sa amo:

Repatriated Problema sa pinagtatrabahuhan ____________________

Problema sa kalusugan

Pang-ekonomiyang Dahilan

At iba pa: ___________________

Petsa ng huling pag-alis ng bansa (PH) (MM/DD/YY) _______________________ (Departure Date)

 Petsa ng pagdating sa bansa (PH) (MM/DD/YY) ___________________________ (Arrival Date)

Mga Bansang Pinagtrabahuhan

Bansa Petsa na dumating sa Uri ng Trabaho Employer

Pilipinas

Documents Available Photocopy of Valid Passport/Travel Document

Photocopy of latest departure stamp on passport.

Photocopy of latest arrival stamp on passport.

Airline Ticket (From Jobsite to Philippines)

Proof of Overseas Employment (Employment Contract, OEC)

Proof of loss of employment due to displacement/distressful situation (POLO Referral, Medical

Report, Copy of Complaint Form from POLO/POEA)
I hereby certify that the information given herein are true and correct to the best of my knowledge.
_________________
Date of Submission