DEPARTMENT OF LABOR AND EMPLOYMENT OSH PRACTITIONER/ DOLE-BWC Please attach your
Bureau of Working Conditions
AF-PCN-A1 1” x 1” picture
Occupational Health and Safety Division CONSULTANT SC: blue background
APPLICATION FORM Revision Code: 0803-0 SP: red background
(New Applicant) Page 1 of 3 2 COPIES
signed at the back
Instructions:
Fill in all the data needed. Use block/printed letters or use a typewriter. Write N.A. if the blanks are not
Applicable. Please sign in all pages of the form.
I would like to apply for Accreditation as: OSH Consultant
X OSH Practitioner
1. PROFILE
Last Name First Name Middle Name Sex: Civil Status:
Valdez Jesus Baradas Single Widower/Widow
X
M F
X Married Separated
City Address (Number & Street, Town/City, Province, Zip Code) Date of Birth: Aug 18 1988 Citizenship: Filipino
Block 55 Lot 5 San Ramon Housing Canlubang, Calamba City,
Height: 170 cm Religion: Roman Catholic
Laguna 4028
Home/Provincial Address Weight: 80 Kg TIN No. : PRC No.(if any):
Same as City Adress Blood Type: A+ 0037117
Business Address SSS/GSIS No. Cellular Phone No (if any):
09202070211
Sinopec Branch Office Jubail City Eastern Province KSA
Home No.: Co. Tel No.:
+966-3-8879065
Nature of Business / Specific Product/ Type of Service : E-mail: Fax No.:
Petrochemical / Construction / Oil and Gas valdezjesusb.081888@yahoo.com +966-3-8879067
Workplace: Employment Size:
Hazardous Non-hazardous 5000+ FEMALE: _____ TOTAL : _____
MALE: ______ 5000+
X
PSIC Code: Region: GEO Code: Zip Code:
4A 4028
2. EDUCATIONAL ATTAINMENT - indicate only tertiary education: Masteral, doctoral. Please attach
photocopy of diploma /transcript of records .
Degree/units Earned School / Address Inclusive dates Awards/ Honors
(Last attended)
B.S. Electrical Engineering Polytechnic University of the Philippines Jun 2005 - May 2010 N/A
Type of Professional License received: ____________________
Registered Master Electrician
PRC License NO.: ________________
0037117 Date Issued: ______________
10/19/2010 Validity: ______________
8/18/2017
3. WORK EXPERIENCE (Use additional sheet if necessary). Please attach original certificate of employment and job
description duly certified by the Personnel Manager/ employer/or authorized company official YEARS OF OSH
using official company letter head; and proof of practice (safety report/programs prepared/implemented). 5+ EXPERIENCE
Position Company
Inclusive Dates Length Status of
(From recent to present)
From To of service Appointment
HSE Supervisor Dec 2011 Present 5+ years Regular Employee Sinopec Engineering Group
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To be accomplished in duplicate Note: This form is NOT FOR SALE. It may be reproduced
DEPARTMENT OF LABOR AND EMPLOYMENT
Bureau of Working Conditions
DOLE-BWC
Occupational Health and Safety Division OSH PRACTITIONER/CONSULTANT AF-PCN-A1
APPLICATION FORM Revision Code: 0803-0
(New Applicant) Page 2 of 3
4. OSH RELATED TRAININGS / SEMINARS ATTENDED ( As Participant ) -. ( Use additional sheet if necessary)
Please attach photocopy of certificate. Original copies of certificates to be presented to authorized DOLE staff for
certification.
No. of Conducted by Venue
Title Time / Duration Hours
(Start from recent to previous) From To
On Separate Page
5. OSH RELATED LECTURES / SEMINARS /TRAININGS CONDUCTED ( As Resource Speaker ) (Use
additional sheet if necessary ) Please attach photocopy of certificate/recognition received.
No. of Conducted by Venue
Title/Topic Time / Duration Hours
(Start from recent to previous) From To
In House Trainings Conducted
In our company for the workers On Separate Page
6. OSH SKILLS / EXPERTISE / SPECIALIZATION ACQUIRED (Use additional sheet if necessary)
Years of
Trade / Occupation Field of Expertise Brief Description
Experience
HSE Supervisor Petrochem/Cons/Oil/Gas Construction of Petrochemical and More than 5 years
Oil and Gas Complex
7. OSH AWARDS / ACHIEVEMENTS /RECOGNITION RECEIVED (Use additional sheet if necessary). Attach
photocopy of certificate of award/recognition
Title Issued by Date Issued
25
To be accomplished in duplicate Note: This form is NOT FOR SALE. It may be reproduced
DEPARTMENT OF LABOR AND EMPLOYMENT
Bureau of Working Conditions OSH PRACTITIONER/CONSULTANT DOLE-BWC
Occupational Health and Safety Division APPLICATION FORM AF-PCN-A1
(New Applicant) Revision Code: 0803-0
Page 3 of 3
8. OSH EXAMINATIONS / ELIGIBILITIES PASSED (if any) (Use additional sheet if necessary). Please attach
photocopy of ID, license or certification
Title Year Taken Given by Rating
9. MEMBERSHIPS / AFFILIATIONS RELATED TO OSH
Organization / Institution / Agency Designation / Position Validity
Member
Philippine Society of Safety Practitioner -
Middle East Region
Institute of Integrated Electrical Engineers Member
10. CHARACTER REFERENCES ( give at least 3)
Name Position / Occupation Company / Address Contact Number/s
Wang Haitao HSE Manager Sinopec Engineering Group +966 505 225 481
Joselito Acosta HSE Manager Saudi Aramco Dow Petrochem Complex +63 995 9880 828
Mukhtiar Ahmed Safety Officer Sinopec Engineering Group +966 595 093 052
Do you have any pending a) administrative case Yes X No b) criminal case? Yes X No
If you have any, give details of the offense _________________________________________________________
Have you been convicted of any crime or violation of any law, decree, ordinance or regulations by any court or
tribunal?
Yes X No If yes, give details _________________________________________________________
Have you ever been convicted of any administrative offense? Yes X No
If your answer is “YES”, give details of the offense __________________________________________________
Have you ever been retired, forced to resign or dropped from employment in the public and private sector?
Yes X No If yes, give reasons __________________________________________________________
I certify that the information stated above are true and correct.
RIGTH THUMB
________________________ Date: _____________ MARK
SIGNATURE
26
To be accomplished in duplicate Note: This form is NOT FOR SALE. It may be reproduced
