Republic of the Philippines

DEPARTMENT OF HEALTH
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PRIMARY CARE WORKERS’ CERTIFICATION PROGRAM
APPLICATION FORM

APPLICANT’S PERSONAL INFORMATION

Name (Last Name, First Name, Middle Name) Suffix/ Extension Name Sex

☐Male

☐Female

Date of Birth (mm/dd/yyyy) Age Citizenship Civil Status

☐Filipino ☐Single ☐Widowed

☐Dual Citizenship; ☐Married ☐ Separated

Country:_________ ☐Others: ____________

Active Mobile Number Active Email Address

Office Email: Personal Email:

Profession PRC License

Number: _____________ Date of Issuance: ____________ Date of Expiration:_____________

EDUCATIONAL BACKGROUND (Most Recent)

Period of Attendance Highest Level/
Year
Level Name of School Degree/ Course Units Earned if
Graduated
From To not graduated

Graduate Studies

Tertiary

PRESENT WORK EXPERIENCE/ HEALTH FACILITY INFORMATION

Position Title Name of Facility Type of Facility

☐Rural Health Unit ☐Private Medical Clinics

☐Municipal/City/Provincial Health Office

☐Birthing Home ☐Hospital/Infirmary

Status of Employment Type of Ownership ☐Barangay Health Station

☐Others, pls. specify: ___________

☐Private-owned ☐Government-owned
PhilHealth eKonsulta Accredited

☐Yes ☐No

Complete Address of the Health Facility Region:

(Floor, Building Name, No., Street, Barangay, Municipal/City, Province, Postal Code) Province:

Municipality/ City:

CURRENT ROLES AND RESPONSIBILITIES (Use separate paper, if necessary)

DOH-PCP-Applicants Information Sheet (Form 1)

Revision 2
December 2022
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I hereby declare that all of the submitted documents and information provided with this application form are true,
correct, and complete pursuant to the provisions of pertinent laws, rules, and regulations of the Republic of the
Philippines.

I authorized the agency head/ authorized representative to verify/ validate the content stated herein.

_________________________________ ___________________
Applicant’s Signature Over Printed Name Date

DOH-PCP-Applicants Information Sheet (Form 1)

Revision 2
December 2022