TSSD-LS09-006

Rev. 00
Effective: 20 Aug 2021

(COMPANY NAME, LOGO & ADDRESS)

CERTIFICATION OF EMPLOYMENT/ENGAGEMENT
THIS IS TO CERTIFY THAT the following are employed/engaged by this company, to
wit:
Type of Name Duration Date of COSH CP#
Personnel Employment/ Training
Engagement
Safety From:
Officer/s:
Until:
From:

Until:

Type of Name Duration of Validity of ID CP#

Personnel Employment/
Engagement
First Aider/s: From:

Until:
From:

Until:

for the project: ________________________________________________________________

____________________________________________________________________________,

located at: ___________________________________________________________________

____________________________________________________________________________.

This certification is issued in compliance with the requirement of DOLE RO5 for the
issuance of Certificate of Approval of Construction Safety and Health Program (CSHP).

I hereby declare and affirm that the above-stated facts, to the best of my knowledge, are
true and correct.

Further, it is understood that the above statements may be the subject of verification by
DOLE RO5 and any falsity or misrepresentation may result in the disapproval of our application
for Certificate of Approval of CSHP or cancellation if one has already been issued

_____________________________________
Signature over printed name of
Owner/President/Manager)
Conforme:

Safety Officer First Aider

________________________________________ ________________________________________
(Signature over printed name) (Signature over printed name)
________________________________________ ________________________________________
(Signature over printed name) (Signature over printed name