Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Intramuros, Manila
Certificate Number: AJA15-0048
ESTABLISHMENT REPORT ON COVID-19
ROVI-CAFO-2020-03-
(Region-PO/FO-Year-Month-Count)
Instructions:
1. Accomplish this form in two copies when filing a notice of: a) Flexible Work Arrangement orb) Temporary Closure.
The report is considered as duly filed when the complete list of workers affected is made part of the submission. Fields with asterisks (*) should
be accomplished by the company representative for COVID-19 Adjustment Measures Program applications.
2. This form should be submitted to the DOLE Regional/Provincial/Field Office as soon as possible.
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*:(Please indicate registered name as reflected in the business permit)

CSC BUILDERS
Floor/Bldg/No/Street/Subdivision*: GROUND FLOOR, RENDON BLDG.,LEGASPI ST., BRGY 3, ROXAS CITY
Barangay/City/Municipality*: BRGY. 3, ROXAS CITY, CAPIZ
Kind of Business/Economic CONSTRUCTION/CONTRACTOR
Activity/Principal Product: CONSTRUCTION OF RESIDENTIAL BUILDING, COMMERCIAL BUILDING,
ETC.
Number of Workers*: Male: 55 Managerial Employees: 2
Female: 04 Supervisory: 4
Total: 59 Rank and File: 53
Total: 59
Date of Filing*:(mm/dd/yyyy) 04/02/2020
B. Summary of Affected Workers due to
B.1 Flexible Work Arrangement*
Type of Flexible Work Arrangement
No. of Workers Effectivity Date
to be Implemented
Covered/Affected (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)
60 03/25/2020 OTH

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) _WORK STOPPAGE DUE TO
ENHANCED QUARANTINE___________

CERTIFICATION
This is to certify as to the accuracy of the data provided in this report.

Name and Signature of Owner/Company Representative*: ENGR. RAMIL S. ARTATES

Designation: Fax No.:

OWNER/PROPRIETOR
Contact No.:
(036) 6217-802/09196319591 Email Address: ramilsartates@gmail.com

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

Updates/Remarks, if any:
Received/Verified by: a) Provision of assistance (please specify)
________________________________________________
b) Estimated date of resumption of normal business operations:
JESSEL V. VALAD-ON___________ ________________________________________________
Name and Signature of DOLE Representative c) Others (please specify)
________________________________________________

Name and Signature of DOLE Representative:

Date: ______________
WILFREDO A. SANTIZO/ OIC HEAD, CAFO
 Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila
Date: ______________
Certificate Number: AJA15-0048

LIST OF AFFECTED WORKERS DUE TO COVID-19

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

ofile of Affected Workers

Employment
Name of Worker* Se Contact Status
No. Age* Home Address* Designation Salary1
(Last Name, First Name, M.I.) x* Number* (regular,
contractual, etc.)
MODESTO, JOSE C BRGY. DUMULOG,
1 50 M 09301690174 FOREMAN CONTRACTUAL Php500/Day
ROXAS CITY

BAGONA, DENNIS B. BRGY. DUMULOG,

2 41 M 09466041004 STEELMAN CONTRACTUAL Php400/Day
ROXAS CITY

CONSOLACION, ROGER A. BRGY. DAYAO, ROXAS

3 31 M 09103465831 HELPER CONTRACTUAL Php350/Day
CITY

APARIJADO, PAQUITO G. BRGY. CULASI, ROXAS

4 62 M 09460917070 HELPER CONTRACTUAL Php350/Day
CITY

AGARAO, JAY-AR A. BRGY. CULASI, ROXAS

5 29 M 09129407277 HELPER CONTRACTUAL Php350/Day
CITY

CELIS, WILFREDO A. BRGY. CULASI, ROXAS

6 62 M 09129407277 MASON CONTRACTUAL Php400/Day
CITY

TABONA, EMMANIEL M. BRGY. CULASI, ROXAS

7 21 M 09129407277 HELPER CONTRACTUAL Php350/Day
CITY

MARTINEZ, GILBERT B. BRGY. DUMULOG,

8 22 M 09385198383 HELPER CONTRACTUAL Php350/Day
ROXAS CITY

BARRES, MIKE D. BRGY. CULASI, ROXAS

9 21 M 09129407277 HELPER CONTRACTUAL Php350/Day
CITY

AGANA, JOHNNY O. BRGY. CULASI, ROXAS

10 47 M 09973909059 MASON CONTRACTUAL Php400/Day
CITY

GALIDO, NONILON A. BRGY. BALIJUAGAN,

11 49 M 09129407277 HELPER CONTRACTUAL Php350/Day
ROXAS CITY

JULLAR, ROBINSON A. POB. ILAWOD, SUPERVISO

12 52 M 09994450654 CONTRACTUAL Php650/Day
PANITAN, CAPIZ R

DELA CRUZ, MAE A. BRGY. DUMULOG,

13 42 F 09466041004 SECRETARY REGULAR Php350/Day
ROXAS CITY

ARTATES, MERLAMINA A. BRGY. DUMULOG,

14 50 F 09203848674 CASHIER REGULAR Php400/Day
ROXAS CITY

ARTATES, STEPHANIE A. BRGY. DUMULOG, DRAFTSMA

15 28 F 09567245154 REGULAR Php450/Day
ROXAS CITY N

DE PEDRO, BRIAN R. BRGY. BAYBAY, ROXAS

16 35 M 09108691270 MASON CONTRACTUAL Php400/Day
CITY

DELANTAR, HERBY E. BRGY. PUNTA COGON,

17 33 M 09303144130 HELPER CONTRACTUAL Php350/Day
ROXAS CITY

ALEJANDRIA, JONATHAN S. BRGY. CUDIAN, IVISAN,

18 37 M 09484202297 MASON CONTRACTUAL Php400/Day
CAPIZ

DELFIN, ANDREW B. BRGY. PUNTA COGON,

19 46 M 09104732240 MASON CONTRACTUAL Php400/Day
ROXAS CITY

20 ARTATES, RAMIL S. 51 M BRGY. DUMULOG, 09196319591 ENGINEER REGULAR Php750/Day

 Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila
ROXAS CITY
Certificate Number: AJA15-0048
ELICANA, WARLITO D. BRGY. DUMULOG,
21 45 M 09101375183 MASON CONTRACTUAL Php400/Day
ROXAS CITY

CALMERIN, JUAN B. BRGY. MANSACUL,

22 19 M 09100700530 HELPER CONTRACTUAL Php350/Day
SAPIAN, CAPIZ

FLORES, BOBBEL G. BRGY. LONOY, ROXAS

23 48 M 09100700530 MASON CONTRACTUAL Php400/Day
CITY

ARTATES, RANDY S. BRGY. DUMULOG, ELECTRICIA

24 48 M 09052496065 CONTRACTUAL Php400/Day
ROXAS CITY N

FABON, EMMANUEL M. BRGY. PUNTA COGON,

25 20 M 09955648147 HELPER CONTRACTUAL Php350/Day
ROXAS CITY

ESMOLADA, ALFREDO D. BRGY. BANICA, ROXAS

26 47 M 09308685238 PAINTER REGULAR Php400/Day
CITY

ESMOLADA, ROLANDO D. BRGY. BANICA, ROXAS

27 46 M 09308685238 PAINTER CONTRACTUAL Php380/Day
CITY

ESMOLADA, ALLAN BRGY. BANICA, ROXAS

28 25 M 09129658235 PAINTER CONTRACTUAL Php350/Day
CHRISTOPHER E. CITY

BRGY. BANICA, ROXAS

29 18 M 09129658235 PAINTER CONTRACTUAL Php380/Day
CITY
ESMOLADA, RENEBOY C.
BRGY. BANICA, ROXAS
30 35 M 09129658235 PAINTER CONTRACTUAL Php400/Day
CITY
ESMOLADA, MANUEL D.

MAPA, FRANCIS C BRGY. SAN JOSE, ROXAS FOREMA

31 38 M 09464146903 CONTRACTUAL Php500/Day
CITY N
BRGY. DUMULOG, ROXAS SUPERVIS
32 DASILAG, JOECEL D. 56 M 09973980827 CONTRACTUAL Php400/Day
CITY OR

OBAFIAL, ROWEL A. BRGY. TANQUE, ROXAS ENGINEE

33 52 M 09225373031 CONTRACTUAL Php600/Day
CITY R
BRGY. ADLAWAN, ROXAS TIME
34 BODEGAS, NIEL E. 34 M 09304231446 CONTRACTUAL Php400/Day
CITY KEEPER

BRGY. DUMULOG, ROXAS ELECTRICI

35 SERIOZA, DEMARK A. 29 M 09103473213 CONTRACTUAL Php400/Day
CITY AN

PAMA, RUEL A. BRGY. MONGPONGI, ROXAS FOREMA

36 42 M 09461272338 CONTRACTUAL Php500/Day
CITY N
37 FAJADER, EMMANUEL I. 34 M BRGY. CULASI, ROXAS CITY 09396459864 WELDER CONTRACTUAL Php500/Day
BRGY. LAWAAN, ROXAS
38 FOTOTANA, HAZEL MARY 29 F 09076213307 WELDER CONTRACTUAL Php500/Day
CITY
JOYCE I.
39 VERTUDAZO, MARTIN V. 35 M POB, SUR. IVISAN, CAPIZ 09385186660 HELPER CONTRACTUAL Php350/Day
BRGY. DUMULOG, ROXAS
40 MORALES, RANDY 37 M 09097737513 HELPER CONTRACTUAL Php350/Day
CITY

BRGY. DUMULOG, ROXAS

41 RUPA, RENE 35 M 09955648147 HELPER CONTRACTUAL Php350/Day
CITY

42 REYES, JUAN D. 53 M BRGY. LIBAS, ROXAS CITY 09076203757 DRIVER REGULAR Php380/Day
BRGY. PUNTA COGON,
43 FUENTES, ROQUE A. 40 M 09096769711 HELPER CONTRACTUAL Php350/Day
ROXAS CITY

BRGY. JUMAGUICJIC,
44 CRISTOBAL, FRANCISCO 48 M 09464146903 MASON CONTRACTUAL Php400/Day
ROXAS CITY
C.
45 JOSELITO OVILLE L. 37 M BRGY. CULASI, ROXAS CITY 09301358770 LEADMAN CONTRACTUAL Php450/Day
46 GASAR, JULIUS 36 M BRGY. CULASI, ROXAS CITY 09464146903 MASON CONTRACTUAL Php400/Day
47 CRISOSTO, CUSTODIO 35 M BRGY. CULASI, ROXAS CITY 09301358770 MASON CONTRACTUAL Php400/Day
48 CARANOO, LLOYD B. 23 M BRGY. CULASI, ROXAS CITY 09301358770 HELPER CONTRACTUAL Php350/Day
49 APAREJADO, RECAR O. 22 M BRGY. CULASI, ROXAS CITY 09301358770 HELPER CONTRACTUAL Php350/Day
 Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila
50 BIEN, JEMAN 23 M BRGY. CULASI, ROXAS CITY 09301358770 HELPER CONTRACTUAL Php350/Day
BRGY. MONGPONG, ROXAS 09301358770 Certificate Number: AJA15-0048
51 BIBIT, VICTOR B. 30 M HELPER CONTRACTUAL Php350/Day
CITY

52 VALIENTE, ALLAN N. 34 M BRGY. CULASI, ROXAS CITY 09301358770 HELPER CONTRACTUAL Php350/Day

ESCOBER, JOWANGKEE 09301358770

53 26 M BRGY. CULASI, ROXAS CITY HELPER CONTRACTUAL Php350/Day
V.
54 PORADERO, RENANTE O. 23 M BRGY. CULASI, ROXAS CITY 09301358770 HELPER CONTRACTUAL Php350/Day
55 SOBERANO, WELSAN G. 22 M BRGY. DAYAO, ROXAS CITY 09301358770 STEELMAN CONTRACTUAL Php400/Day
56 AGANA, LESTER D. 24 M BRGY. CULASI, ROXAS CITY 09301358770 HELPER CONTRACTUAL Php350/Day
57 LOYOLA, EDNEL T. 24 M BRGY. CULASI, ROXAS CITY 09301358770 HELPER CONTRACTUAL Php350/Day
58 DE ANDRES, ROMY O. 25 M BRGY. CULASI, ROXAS CITY 09301358770 HELPER CONTRACTUAL Php350/Day

URETA, RICARDO A. 09301358770 CARPENTE

59 48 M BRGY. CULASI, ROXAS CITY CONTRACTUAL Php400/Day
R

60

ndicate whether per hour, per day or per month

Mandatory fields to be accomplished by the company representative for COVID-19 AMP applications.

repared by:

gnature over Printed Name

NGR. RAMIL S, ARTATES

ate: 04/02.2020

CAN AND E-MAIL