Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Intramuros, Manila

ESTABLISHMENT REPORT ON COVID-19

_________________NCR________________
(Region-PO/FO-Year-Month-Count)
(ex. NCR-MFO-2020-02-001)

Instructions:
1. Accomplish this form in two copies when filing a notice of: a) Flexible Work Arrangement or b) Temporary Closure.
The report is considered as duly filed when the complete list of workers affected is made part of the submission.
2. This form should be submitted to the DOLE Regional/Provincial/Field Office at least thirty (30) calendar days prior to
the effectivity of temporary closure or at least one (1) week prior to the implementation of FWA.
3. Page 1 should contain general information about the establishment and the number of workers affected.
4. Page 2 should enumerate the names of workers affected, their addresses and contact numbers, position title and
salary.
5. Total number of workers listed should equal the total number of workers affected as reported in this page.

A. Establishment Data

Name of Establishment: LUZON RAM CYCLES, INC.

Floor/Bldg/No/Street/Subdivision: #50 M.H DEL PILAR ST
Barangay/City/Municipality: BRGY TUGATOG MALABON CITY
Kind of Business/Economic
Activity/Principal Product: MOTORCYCLE DEALER / SELLER
Number of Workers: Male: 23 Managerial Employees: 1
Female: 7 Supervisory: 10
Total: 30 Rank and File: 19
Total: 30
Date of Filing: (mm/dd/yyyy) MARCH 19, 2020

B. Summary of Affected Workers due to

B.1 Flexible Work Arrangement
No. of Workers
Covered/Affected
Type of Flexible Work Arrangement
Effectivity Date
to be Implemented
(mm/dd/yyyy)
(Use code below, select only one)

Codes for Flexible Work Arrangement Scheme:

 RW - Reduction of Workdays  FL - Forced Leave
 RE - Rotation of Employees  OTH - Others (Specify) ____________

B.2 Temporary Closure

No. of Workers Effectivity Date Main Reason of Temporary Closure
Covered/Affected (mm/dd/yyyy) (Use code below, select only one)
30 MARCH 16,2020 I

Codes for Main Reason for Temporary Closure:

 LM - Lack of Market/Slump in Demand  I - Infection (COVID-19)
 LRM - Lack of Raw Materials  OTH - Others (Specify) ____________

CERTIFICATION
This is to certify as to the accuracy of the data provided in this report.
Name and Signature of Owner/Company Representative:
CHRISTOPHER F. BORREROS
Designation: Fax No.:
SUPERVISOR
Contact No.: 09322981296 Email Address: bheamaegubalane@gmail.com

FOR DOLE (Regional/Provincial/Field Office) USE ONLY:

Updates/Remarks:
a) Provision of assistance (please specify)
_______________________________________________________
b) Estimated period of resumption of normal business operations: ____________________________________
c) Others (please specify)
____________________________________________________________________

Name and Signature of DOLE Authorized Representative: Date Updated:

 Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila

LIST OF AFFECTED WORKERS DUE TO COVID-19

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

Profile of Affected Workers

Employme
No Name of Worker Contact nt Status
Age Sex Home Address Designation Salary1
. (Last Name, First Name, M.I.) Number (regular,
contractual, etc.)
FIELD REPRESENTATIVE
1
ACUPAN,EUGENE A. 30 M MALABON CITY 09129112951 REGULAR 14,500

FIELD REPRESENTATIVE
2
AVENDAÑO,BILLY D. 30 M MALABON CITY 09094873989 REGULAR 14,500

FIELD REPRESENTATIVE
3
BARILLA, JOHN MARK H. 33 M MALABON CITY 09652682539 REGULAR 14,500

FIELD REPRESENTATIVE
4
BINGCO,EDESON P. 23 M MALABON CITY 09272226849 REGULAR 14,500

BORREROS,
5
CHRISTOPHER F. 31 M CALOOCAN CITY 09322981296 SUPERVISOR REGULAR 14,500

CABIO,MARK ANTHONY
6
P. 40 M CALOOCAN CITY 09224849619 SUPERVISOR REGULAR 16,000

CARABOT, EMMIE LIZA

7
S. 24 F CALOOCAN CITY 09101820468 SUPERVISOR REGULAR 14,500

8 CARREON,JONELL V. 25 M MALABON CITY 09563893356 MECHANIC REGULAR 14,500

CASTILLO,CHERRY ANN
9
A. 22 F CALOOCAN CITY 09468414979 SUPERVISOR REGULAR 14,500

10
COLONIA,ROMELE T. 27 M MALABON CITY 09981723345 SUPERVISOR REGULAR 14,500
DE LOS REYES,NELSON
11
C. 25 M CALOOCAN CITY 09500000039 FIELD REPRESENTATIVE REGULAR 14,500

DELA CRUZ,REDENTOR
12
G. 24 M MALABON CITY 09223633764 SALES REGULAR 14,500

13 DUHIG,ROBERT RYAN V. 34 M MALABON CITY 09663070608 MECHANIC REGULAR 14,500

14 ESIC, DANNY S. 32 M MALABON CITY 09169944826 MANAGER REGULAR 16,000

15
ESIC, LYNE PAUL C. 28 F MALABON CITY 09989693130 AREA SUPERVISOR REGULAR 16,000

16 GITANO,EDISON S. 37 M MALABON CITY 09462370027 MECHANIC REGULAR 14,500

GUBALANE,BHEA MAE
17
N. 22 F MALABON CITY 09363415870 CASHIER REGULAR 14,500
FIELD REPRESENTATIVE
18
LEONARDO,JERVY P. 31 M MALABON CITY 09232124569 REGULAR 14,500
19 LIGUTOM,AILEEN L. 32 F MALABON CITY 09305434108 SUPERVISOR REGULAR 15,000

20 LOPEZ,JOSEPH Q. 33 M MALABON CITY 09429764731 WARRANTY REGULAR 14,500

LOVINO,JUNREY A. 24 M MALABON CITY 09555402937 FIELD REPRESENTATIVE REGULAR 14,500

21

22 MARGEN,MARIO JR . I. 29 M MALABON CITY 09302770478 SUPERVISOR REGULAR 14,500

23 MIRO,GERMAINE C. 32 M MALABON CITY 09365622186 MECHANIC REGULAR 14,500

24 PAMOLANGUE,JOEY T. 30 M CALOOCAN CITY 09994999794 MECHANIC REGULAR 14,500

REMAN,JERAMEEL D. 23 M CALOOCAN CITY 09222258978 FIELD REPRESENTATIVE REGULAR 14,500

25

REYNOSO,WILFREDO 30 M MALABON CITY 09499548856 SUPERVISOR REGULAR 16,000

26
JR.U.
 Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila

27 SANARES,SANDRO D. 28 M MALABON CITY 09218972392 SALES REGULAR 14,500

SANTIAGO,MARIA 22 F MALABON CITY 09361600284 SALES REGULAR 14,500

28
SHARENA J.

29 TARTAR,REGINE O. 23 F MALABON CITY 09463593945 SUPERVISOR REGULAR 14,500

30 TRAQUENA,EDWIN S. 63 M CALOOCAN CITY 09224676330 MECHANOC REGULAR 15,000

1
Indicate whether per hour, per day or per month