DOLE-GIP_FORM A

DOLE REGIONAL OFFICE 8

GOVERNMENT INTERNSHIP PROGRAM (GIP)

APPLICATION FORM
INSTRUCTION TO APPLICANTS:
Please fill-out all the required information in this form and attach additional documents, if necessary.
1 NAME OF APPLICANT:

Family Name First Name Midddle Name

2 RESIDENTIAL ADDRESS:

GSIS beneficiary: Relationship:Relatives

Mobile Number:
E-mail Address:
3 PLACE OF BIRTH (city/province)
4 DATE OF BIRTH (mm/dd/yyyy)
5 GENDER MALE FEMALE

6 CIVIL STATUS SINGLE MARRIED WIDOW/WIDOWER

7 EDUCATION ATTAINMENT
INCLUSIVE DATES
NAME OF SCHOOL (No Abbreviations) DEGREE OR DIPLOMA
From To
Elementary
Secondary Others
Tertiary
Tech-Voc
CERTIFICATION: I certify that all information given in this application are complkete and accurate to the best of my knowledge.
I acknowledge that I have completely read and understood the DOLE-GIP Guidelined as embodied in Administrative Order No. 39,
Series of 2014.

DATE SIGNATURE OF APPLICANT

FOR DOLE-RO/FO Use only

Interviewed and validated by:

ENGR. ERWIN BARBARONA

LEO III
NAME and SIGNATURE/Position DATE

Notes:
Place of Assignment

Employment Period to

Work Contact Person

Contact Number:
 DOLE-GIP Form B

DEPARTMENT OF LABOR AND EMPLOYMENT

GOVERNMENT INTERNSHIP
(DOLE-GIP)

INTERNSHIP AGREEMENT

THIS AGREEMENT is made by and between the Department of Labor and Employment as
represented by Director HENRY JOHN S. JALBUENA of the DOLE Regional Office No. VIII with office
address at Trece Martirez St. Tacloban City.

-and-

__________________________, of legal age and with postal address in

_____________.
WITNESSETH:

1. This Agreement shall govern the relationship of the Intern and the Government Office where
he/she will be assigned and does not create any employer-employee relationship between the
DOLE and the Intern;

2. That the duration of this Agreement shall be for a period of three (3)/ six (6) months to be in force and
effect within 2022, counting from the date that the Intern reported to his/her work assignment,
as shown in the effective start date below;

3. That in cases where the Intern will not be able to finish the period of three (3)/ six (6) months internship
program, shall inform/notify the Government Office where the internship is rendered
through his/her immediate Supervisor, and report to the DOLE-RO the intention of ending this
Agreement at an earlier date.

4. That the Intern shall be entitled to receive an allowance/stipend equivalent at 100% of the
existing Regional minimum wage where the internship agreement shall be enforced, payable
every 15th and 30th of each month based on the Intern’s actual attendance, and that absences,
tardiness or under time incurred shall be deducted accordingly; and

5. That the DOLE-RO shall enroll the Intern and pay the one-time GSIS premium in the amount
prescribed by the GSIS for coverage of P100,000, which shall be no later than one (1) week after
the Intern has reported work while this Agreement is in effect, or during the period Internship.

Effective start date: ________ _____________

Effective end date: _________________ _

Office and Place of Assignment: _____ _____________________________

Work/Details of Assignment: Clerical Function

Work Contact Person: ___________________________________

Confidentiality: The Intern must maintain confidentiality, when and where appropriate, during and
after the Internship, of all the data and information where such information is not already within the
public domain and is indicated or understood to be confidential.
IN WITNESS WHEREOF, both parties have hereunto set their hands this
in Catarman, Northern Samar.

By the Authority of: Signed:_____________________

HENRY JOHN S. JALBUENA The Intern: _______________________

Regional Director

ENGR. PRIMO N. GUARIN

VIRGILIO
ENGR. A.N.DOROJA,
PRIMO GUARIN JR.
Provincial Head, NSFO

ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES)

Catarman, Northern Samar) S.S

BEFORE ME, a Notary Public for and in the above jurisdiction, personally appeared the
following:

NAME IDENTIFICATION CARD/ PLACE

NUMBER ISSUED

1. VIRGILIO A. DOROJA,
ENGR. PRIMO JR.
N. GUARIN ____________/ Tacloban City

2. GIP ID Catarman, N. Samar

known to me to be the same persons who executed the foregoing instrument and
acknowledged to me that the same is their own free will and voluntary act and deed.

This instrument consists of two (2) pages including this page wherein this Acknowledgement is
written and is signed by the parties and their instrumental witnesses on every page hereof.

WITNESS MY HAND AND SEAL, this __day of ___________, 2022 in _____________________.

_________________________
NOTARY PUBLIC
Doc. No: ______;
Page No: ______;
Book No: _____;
Series of 2022
Attach the notarized copy of the Internship Agreement here.

Attach Page 2 of Notarized Internship Agreement here

Attach the first page of you Diploma/ TOR here.

Attach Scanned Copy of TOR here

Attach the second page of your Diploma/ TOR here.

Attach page 2 of TOR here

Attach your Marriage Certificate here, for married female GIP applicants.