Republic of the Philippines

DEPARTMENT OF HEALTH
PRIMARY CARE WORKERS’ CERTIFICATION PROGRAM
APPLICATION FORM
APPLICANT’S PERSONAL INFORMATION
Name (Last Name, First Name, Middle Name) Suffix/ Extension Name Sex
Domingo, Elvira Mamaid N/A ☐Male
🗹Female
Date of Birth (mm/dd/yyyy) Age Citizenship Civil Status
🗹Filipino ☐Single ☐Widowed
October 15, 1975 48 ☐Dual Citizenship; 🗹Married ☐ Separated
Country:_________ ☐Others: ____________
Active Mobile Number Active Email Address
0926-097-3810 Office Email: Personal Email: elviradomingo1575@gmail.com
Profession PRC License
Midwife Number: 0105647 Date of Issuance: 03/23/1995 Date of Expiration: 10/15/2026

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 N/A
Tertiary De Ocampo Midwifery 1992 1994 N/A 1994
Memorial College
PRESENT WORK EXPERIENCE/ HEALTH FACILITY INFORMATION
Position Title Name of Facility Type of Facility
☐ Rural Health Unit ☐ Private Medical Clinics
Midwife Anabu 1-C Barangay Health Center ☐ Municipal/City/Provincial Health Office
☐ Birthing Home ☐ Hospital/Infirmary
Status of Employment Type of Ownership 🗹 Barangay Health Station
☐Private-owned 🗹Government-owned ☐ Others, pls. specify: ___________
Contractual
PhilHealth eKonsulta Accredited
☐Yes 🗹No
Complete Address of the Health Facility Region: IV-A Calabarzon
(Floor, Building Name, No., Street, Barangay, Municipal/City, Province, Postal Code)
Barangay Health Center, Barangay Anabu 1-C Liwayway Subdivision Province: Cavite
Imus City, Cavite Municipality/ City: Imus City
CURRENT ROLES AND RESPONSIBILITIES (Use separate paper, if necessary)
conducts home visit to households for monitoring of pregnant and postpartum mothers; assists the health facility in the
identification of clients with unmet modern family planning; assists in family planning program services such as
counseling, postpartum family planning, and outreach missions; provides direct maternal and child care services;
participates in data gathering and response during health emergencies and disasters; conducts expanded program
immunization

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.

Elvira M. Domingo 04-19-2024

Applicant’s Signature Over Printed Name Date
DOH-PCP-Applicants Information Sheet (Form 1)
Revision 2
December 2022