concorsarre 1 Soares epi the Pepies fe ro nt. @ DEPARTMENT OF LABOR AND EMPLOYMENT OCCUPATIONAL SAFETY AND HEALTH CENTER aii freon weeps REGISTRATION FORM Training Title, Control Number Date Venue * OSHC assures the strict confidentiality of oll data obtained from the participants Participant's Details Name: Tast Name First Name Middle Name Sulfix(eg. ir, Sr, i) Nickname Date of Birth: Sex: Mobile No.: Company Name: Position: Department/Section: Company Address: Street Municipalty/Gity Province Region Zip Code Company Contact No, Email Address: Company Website: Industry Type: Total No. of Workers: For PRC Licensees only Profession: License Number: Consent By filling out this form and signing below, | am giving my consent to the Occupational Safety ‘and Health Center (OSHC) to collect, process, retain, and store my personal data in accordance with the provisions of Republic Act 10173 - Data Privacy Act of 2012. | further give my consent for the video recording of the conduct of training. ‘Signature over For OSHC use only Payment: Full © Partial Date: (amount) (amount) OR No. ‘OR No. = Uncontroll Date released: Released by: