OSH APPLICATION RENEWAL

TO BE ACCOMPLISHED IN DUPLICATE
This form is
NOT FOR SALE and may be REPRODUCED
DEPARTMENT OF LABOR AND EMPLOYMENT

Occupational Safety and Health Center
OSH-C-N
APPLICATION FORM FOR OSH CONSULTANT (NEW)
Page 1 of 4
INSTRUCTIONS:
1. Fill in all the data needed.
2. Use BLOCK/PRINTED letters or use a TYPEWRITER.
3. Write N/A if the blanks are Not Applicable.
4. Please sign in all pages of the form.
Please attach your

1 X 1 Picture
2 COPIES
Signed at the
back
PERSONAL PROFILE
TITLE
LASTNAME
FIRST NAME
MIDDLENAME
City Address (Number & Street, Town/City, Province,

Zip Code)
Home Tel.
No.
Mobile No.
E-mail
PRC License
No.
Home/ Provincial Address
Date of
Birth
Sex
Citizenship
Civil
Status
COMPANY PROFILE
Business Address
Nature of Business
E-mail Address
Co. Tel. No.
Region
Website
Fax No.
Zip Code
Employment Size
Male
Female
Total
Type of Service
Workplace
Specific Product
Hazardous
Non-Hazardous
WORK EXPERIENCE (Use additional sheet if necessary).

Total OSH EXPERIENCE
Please attach original certificate of employment and job
description duly certified by the Personnel
Manager/employer/ or authorized company official using
official company letter head; and proof of practice (safety
report/programs prepared/implemented)
Inclusive
Length
Status of
Position (From Recent to
Dates
of
Appointme
Company
Present
Service
nt
From
To
This form is

OSH-C-N
Page 2 of 4
DOCUMENTARY REQUIREMENTS
REMARKS
1. Two (2) copies of duly accomplished Application Form (OSHC-N) with 2 copies most recent 1 x 1 ID picture signed at the
back (blue background).
2. Original Certificate of Employment indicating name, position
and date of appointment at present position using the official
letterhead of the company.
3. Original of actual Duties and Responsibilities at present
position, signed by immediate supervisor and Personnel
Manager or authorized official of the company, using
letterhead of the company
4. Photocopy of certificate of employment from previous
employer/s indicating position(s) and date(s) of appointment
(if any and necessary in support of actual experience on
OSH). May submit list of actual functions and proof of
accomplishments, duly certified by the employer.
5. Photocopy of certificate of completion of the DOLE prescribed
advance course (80-hr) on Occupational Safety and Health
issued by accredited STO.
6. Photocopy of certificate of attendance/participation on other
OSH related trainings/seminars/activities.
7. Photocopy of College Diploma or Transcript of Records and
Board Exam Certificate or PRC License (if any).
8. Submission of summarized OSH trainings with a total of at
least 480 hours. Attach photocopy of certificates (Refer to
table below for format)
Table
Title
Issued by
Inclusive Dates
9. Proof/s of accomplishment or participation in OSH

____ Accident reports
_____ Safety inspection/audit
reports
____ HSC committee report _____ OSH program prepared/
implemented
10.Other reports prepared by the applicant please specify ______
OSH RELATED LECTURES/TRAININGS/SEMINARS ATTENDED - As Resource Speaker

(Use additional sheet if necessary). Please attach photocopy of certificate/recognition received.
Title/Topic
(From recent to previous)
Time/Duration
No. of
Hours
Conducted
by
Venue
This form is

OSH-C-N
Page 3 of 4
OSH SKILLS/EXPERTISE/SPECIALIZATION ACQUIRED (Use additional sheet if necessary)

Trade/Occupation
Field of Expertise
Brief Description
Years of
Experience
OSH AWARDS/ACHIEVEMENTS/RECOGNITION RECEIVED (Use additional sheet if

necessary)
Please attach photocopy of certificate of award/recognition.
Title
Issued by
Date Issued
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
MEMBERSHIPS/AFFILIATIONS RELATED TO OSH

Organization/Institution/Agency
Designation
Validity
This form is

OSH-C-N
Page 4 of 4
CHARACTER REFERENCES (Give at least 3)

Name
Address
Contact No.
E-mail Address
Do you have any pending administrative case? (Yes/No) If YES, please give details.
Do you have any pending criminal case? (Yes/No) If YES, please give details.
Have you ever convicted of any administrative offense?(Yes/No) If YES, please give details.
Have you been convicted of any crime or violation of any law, decree, ordinance or
regulations by any court or tribunal? (Yes/No) If YES, please give details.
Have you ever been retired, forced to resign or dropped from employment in the public
and/or private sector? (Yes/No) If YES, please give reasons.
I certify that the information stated above is true and correct.
SIGNATURE
DATE
This form is

OSH-C-R
APPLICATION FORM FOR OSH CONSULTANT (RENEWAL)
Page 1 of 4
Accreditation NO.: __________________

Date of First
Accreditation:_______________
Date of Last
renewal:_________________
Validity:___________________________
TITLE
LASTNAME
INSTRUCTIONS:
1. Fill in all the data needed.
2. Use BLOCK/PRINTED letters or use a
TYPEWRITER.
3. Write N/A if the blanks are Not
Applicable.
4. Please sign in all pages of the form.
PERSONAL PROFILE
FIRST NAME
MIDDLENAME
City Address (Number & Street, Town/City, Province,

Zip Code)
Please attach
your
1 X 1 Picture
2 COPIES
Signed at the
back
Home Tel.
No.
Mobile No.
E-mail
PRC License
No.
Home/ Provincial Address
Date of
Birth
Sex
Citizenship
Civil
Status
COMPANY PROFILE
Business Address
Nature of Business
E-mail Address
Co. Tel. No.
Region
Website
Fax No.
Zip Code
Employment Size
Male
Female
Type of Service
Workplace
Total
Hazardous
Specific Product
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 using official
company letter head; and proof of practice (safety report/programs
prepared/implemented)
Inclusive
Length
Status of
Position (From Recent to
Dates
of
Appointme
Present
Service
nt
From
To
This form is
Non-Hazardous
Total Years of
OSH Experience
Company

OSH-C-R
Page 2 of 4
DOCUMENTARY REQUIREMENTS
REMARKS
Two (2) copies of duly accomplished Application Form (OSH-C-R)
with 2 copies most recent 1 x 1 ID picture signed at the back
(blue background).
Summary of Applicants Accomplishments as OSH Consultant
signed by the employer or supervisor using official letterhead of
the company.
Proof/s of accomplishment or participation in OSH:
____ Accident reports
_____ Safety inspection/audit
reports
____ HSC committee report ____ _OSH program prepared/
implemented
____ Other reports prepared by the applicant please specify
______
Photocopy of Certificate of Accreditation (last issued)
Photocopy of other OSH related trainings/seminar attended as
participant after last renewal of accreditation- at least 16 hours
per year or 48 hours of trainings for 3 years, earned from DOLE
recognized/accredited STO/institutions authorized by law.
When There is a Change of Employer/Position:
Original Certificate of Employment indicating name, position
and date of appointment at present position, using official
letterhead of the company.
Original Certificate of actual Duties and Responsibilities at
present position, using official letterhead of the company,
signed by immediate supervisor and Personnel Manager or
authorized official of the company.
INITIAL EVALUATION/REMARKS
Complete documents submitted, signed in all pages
With incomplete documents, for compliance of the above stated
deficiencies with mark X.
For interview on _________ at _____, please call
______________________
Others, specify _________________

Submission of summarized OSH trainings attended as
participant. Attach photocopy of certificates ( Refer to table
below for format)
Table
Title
Issued by
Inclusive Dates
This form is

OSH-C-R
Page 3 of 4
OSH RELATED LECTURES/TRAININGS/SEMINARS ATTENDED - As Resource Speaker

(Use additional sheet if necessary). Please attach photocopy of certificate/recognition received.
Title/Topic
No. of
Time/Duration
Conducted by
Venue
(From recent to previous)
Hours
OSH SKILLS/EXPERTISE/SPECIALIZATION ACQUIRED (Use additional sheet if necessary)

Years of
Trade/Occupation
Field of Expertise
Brief Description
Experience
OSH AWARDS/ACHIEVEMENTS/RECOGNITION RECEIVED

(Use additional sheet if necessary) Please attach photocopy of certificate of award/recognition.
Title
Issued by
Date Issued
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
MEMBERSHIPS/AFFILIATIONS RELATED TO OSH

Organization/Institution/Agency
Designation
This form is
Validity

OSH-C-R
Page 4 of 4
CHARACTER REFERENCES (Give at least 3)

Name
Address
Contact No.
E-mail Address
Do you have any pending administrative case? (Yes/No) If YES, please give details.
Do you have any pending criminal case? (Yes/No) If YES, please give details.
Have you ever convicted of any administrative offense? (Yes/No) If YES, please give details.
Have you been convicted of any crime or violation of any law, decree, ordinance or
regulations by any court or tribunal? (Yes/No) If YES, please give details.
Have you ever been retired, forced to resign or dropped from employment in the public
and/or private sector? (Yes/No) If YES, please give reasons.
I certify that the information stated above are true and correct.
SIGNATURE
DATE
NOT FOR SALE and maybe REPRODUCED

This form is
OSHCO-N
APPLICATION FORM FOR OSH CONSULTING

ORGANIZATION - NEW
Page 1 of 2
INSTRUCTION
Please accomplish completely and attach the required documents. Refer to checklist of
requirements listed below for attachments new and mark in the left portion all documents
submitted.
Pursuant to requirement of D.O. 16, series 2001, We would like to apply for an
accreditation as
SAFETY CONSULTING ORGANIZATION
Name of Organization
Company Address
Name of Top Company Head

Telephone No.
TIN No.
Official Title/Designation
Fax No.
Employment
Size
E-mail Address
Male
Female
Total
Website
CHECKLIST OF REQUIREMENTS
1. Duly accomplished application form.
2. Certified true copy of Business Registration with SEC or DTI
whichever is applicable
3. Certified true copy of Mayors Permit/License to operate.
4. Certified true copy of Registration with DOLE Regional Office.
5. Certified true copy of Registration with BIR.
6. Contract of Agreement with Consultant/Resource Person with valid
accreditation.
7. Resume of Consultants and copy of Certificate of Accreditation.
Received by:
Evaluators Remark
(This COLUMN is
to be
accomplished by
OSHC)
REMARKS
(Signature over printed

name)
Position:
Region:
Date/Time:

This form is
OSHCO-N

ORGANIZATION - NEW
Page 2 of 2
Staff Please attach your organizational chart

Name of
Administrative/
Support Staff
Position
Type of Employment
(Regular, Project
Based, Contractual)
Educational
Background
If contractual
(specify period of
contract)
Technical Use additional sheet if necessary. Please attach resume of technical staff/resource
speakers and contract of agreements with them.
Name of Technical Staff
Highest Educational
Attainment
Field of
expertise/specialization/
competence
Office Facilities, Equipment and Material and Office Personnel

A. Office is located in suitable location having a business-like environment accessible to
means of public transportation and with proper identification.
B. Has at least 3 office tables and chairs.
C. Office has sufficient space to move around comfortably. With at least 25 sq. Meter.
D. Lighting and ventilations are adequate.
E. Has at least one set of each of the following items: Telephone, fax machine and other
suitable communication equipment.
F. Has at least one set of working computer and printer.
G. Has one regular staff available to answer telephone calls and queries during office
hours.
H. Has a person authorized to issue company decisions.
I. Receiving area has at least 1 table and chairs for staff & clients.
If accredited as
OSH Professional,
specify
Accreditation No.
and Validity
REMARKS
J.
K.
L.
M.
N.
Meeting or briefing room can accommodate at least 6 persons.

Files and equipment are properly stored, labelled and well secured.
There is suitable storage area/place for equipment and records.
Has at least one regular subscription to safety and health related materials.
Maintains an updated library of safety and health materials, books, standards and
related materials.
O. Has equipment/materials necessary for the type of OSH consultancy services.
P. Has clean and sanitized comfort room.
Type of OSH Consultancy Please attach list of available equipment necessary in the conduct of
type of OSH consultancy, services, provided. Attach also list of clients (if any)
Type of Services Provided
OSH Safety Program Development and
Fire Prevention, Protection and Control Risk
Implementation
Assessment
OSH Safety Audit/Evaluation
Work Environment Measurement
Occupational Safety Management System
Work Accident Investigation
In-Plant Safety Inspection
Other, Please specify
SIGNATURE
DATE
This form is
OSH
CO-R


ORGANIZATION - RENEWAL
Page 1 of 2
INSTRUCTION
submitted.
Pursuant to requirement of D.O. 16, series 2001, We would like to apply of the renewal of
accreditation as
SAFETY CONSULTING ORGANIZATION
Accreditation No.:
Date of First Accreditation:
Date of Last Renewal:
Company Address
Validity:
Telephone No.
TIN No.
Fax No.
Employment
Size
E-mail Address
Male
Female
Total
Website
8. Duly accomplished application form.
9. Certified true copy of Business Registration with SEC or DTI
whichever is applicable.
(This COLUMN is
to be
accomplished by
OSHC)
REMARKS
10.
Certified true copy of Mayors Permit/License to operate.
11.
Certified true copy of Registration with DOLE Regional Office.
12.
Certified true copy of Registration with BIR.
13.
Contract of Agreement with Consultant/Resource Person with
valid accreditation.
14.
Resume of Consultants and copy of Certificate of
Accreditation.
Received by:
Evaluators Remark
name)
Position:
Region:
Date/Time:
This form is


OSHCOR
Page 2 of 2

Name of
Administrative/
Support Staff
Position
Type of Employment
(Regular, Project
Based, Contractual)
Educational
Background
If contractual
(specify period of
contract)
Highest Educational
Attainment
Field of
competence

Q. Office is located in suitable location having a business-like environment accessible to
means of public transportation and with proper identification.
If accredited as
OSH Professional,
specify
Accreditation No.
and Validity
REMARKS
R.
S.
T.
U.
Has at least 3 office tables and chairs

Office has sufficient space to move around comfortably. With at least 25 sq. Meter.
Lighting and ventilations are adequate.
Has at least one set of each of the following items: Telephone, fax machine and other
V. Has at least one set of working computer and printer.
W. Has one regular staff available to answer telephone calls and queries during office
hours.
X. Has a person authorized to issue company decisions.
Y. Receiving area has at least 1 table and chairs for staff & clients.
Z. Meeting or briefing room can accommodate at least 6 persons.
AA. Files and equipment are properly stored, labelled and well secured.
BB. There is suitable storage area/place for equipment and records.
CC. Has at least one regular subscription to safety and health related materials.
DD.Maintains an updated library of safety and health materials, books, standards and
related materials.
EE. Has equipment/materials necessary for the type of OSH consultancy services.
FF. Has clean and sanitized comfort room.
Type of OSH Consultancy Please attach list of available equipment necessary in the conduct of
type of OSH consultancy, services, provided. Attach also list of clients (if any)
Type of Services Provided
OSH Safety Program Development and
Fire Prevention, Protection and Control Risk
Implementation
Assessment
OSH Safety Audit/Evaluation
Work Environment Measurement
Occupational Safety Management System
Work Accident Investigation
In-Plant Safety Inspection
Other, Please specify
SIGNATURE
DATE
This form is
OSHSTO-N

APPLICATION FORM FOR OSH TRAINING

ORGANIZATION - NEW
Page 1 of 2
INSTRUCTION
submitted.
Pursuant to requirement of D.O. 16, series 2001, We would like to apply for an
accreditation as SAFETY TRAINING ORGANIZATION
Company Address

Telephone No.
TIN No.
Fax No.
Employment
Size
E-mail Address
Male
Female
Total
Website
(This COLUMN is to
be accomplished
15.
Duly accomplished application form.
16.
Certified true copy of Business Registration with SEC or DTI
17.
18.
19.
20.
valid accreditation
21.
Contract of Agreement with training venue (for applicant
without training venue)
22.
Resume of Consultant/Resource Person and copy of
Certificates of Accreditation and Trainers Training
Received by:
Evaluators Remark
by OSHC)
REMARKS

name)
Position:
Region:
Date/Time:
This form is


ORGANIZATION - NEW
OSHSTO-N
Page 2 of 2

Name of
Administrative/
Support Staff
Position
Educational
Background
Type of Employment
(Regular, Project
Based, Contractual)
If contractual
(specify period of
contract)
Highest Educational
Attainment
Field of
If accredited as
OSH Professional,
competence
specify
Accreditation No.
and Validity
REMARKS
GG.Office is located in suitable location having a business-like environment accessible to

means of public transportation and with proper identification
HH.Has at least 3 office tables and chairs.
II. Office has sufficient space to move around comfortably. With at least 25 sq. Meter.
JJ. Lighting and ventilations are adequate.
KK. Has at least one set of each of the following items: Telephone, fax machine and other
LL. Has at least one set of working computer and printer.
MM.
Has one regular staff available to answer telephone calls and queries during office
hours.
NN.Has a person authorized to issue company decisions.
OO.Receiving area has at least 1 table and chairs for staff & clients.
PP. Meeting or briefing room can accommodate at least 6 persons.
QQ.Files and equipment are properly stored, labelled and well secured.
RR. There is suitable storage area/place for equipment and records.
SS. Has at least one regular subscription to safety and health related materials.
TT. Maintains an updated library of safety and health materials, books, standards and
related materials.
UU. Has equipment/materials necessary for the type of OSH trainings provided (e.g. LCD
projector, laptop/computer, sample PPE).
VV. Has clean and sanitized comfort room.
SIGNATURE
DATE
This form is


OSH-STOR
Page 1 of 2
INSTRUCTION
submitted.
Pursuant to requirement of D.O. 16, series 2001, We would like to apply of the renewal of
accreditation as
SAFETY TRAINING ORGANIZATION
Accreditation No.:
Date of First Accreditation:
Date of Last Renewal:
Company Address
Validity:
Telephone No.
Fax No.
TIN No.
Employment
Size
E-mail Address
Male
Female
Total
Website
23.
Duly accomplished application form.
24.
Certified true copy of Business Registration with SEC or DTI
25.
26.
27.
28.
valid accreditation.
29.
Resume of Consultant/Resource Person and copy of
Certificate of Accreditation.
Received by:
Evaluators Remark
(This COLUMN is to
be accomplished
by OSHC)
REMARKS

name)
Position:
Region:
Date/Time:
This form is

APPLICATION FORM FOR OSH TRAINING ORGANIZATION

- RENEWAL
OSH-STOR
Page 2 of 2

Name of
Administrative/
Support Staff
Position
Educational
Background
Type of Employment
(Regular, Project
Based, Contractual)
If contractual
(specify period of
contract)
Highest Educational
Attainment
Field of
competence
If accredited as
OSH Professional,
specify
Accreditation No.
and Validity
REMARKS
WW.
Office is located in suitable location having a business-like environment accessible
to means of public transportation and with proper identification.
XX. Has at least 3 office tables and chairs.
YY. Office has sufficient space to move around comfortably. With at least 25 sq. Meter.
ZZ. Lighting and ventilations are adequate.
AAA.
Has at least one set of each of the following items: Telephone, fax machine and
other suitable communication equipment.
BBB.
Has at least one set of working computer and printer.
CCC.
Has one regular staff available to answer telephone calls and queries during office
hours.
DDD. Has a person authorized to issue company decisions.
EEE.
Receiving area has at least 1 table and chairs for staff & clients.
FFF.Meeting or briefing room can accommodate at least 6 persons.
GGG. Files and equipment are properly stored, labelled and well secured.
HHH. There is suitable storage area/place for equipment and records.
III. Has at least one regular subscription to safety and health related materials.
JJJ. Maintains an updated library of safety and health materials, books, standards and
related materials.
KKK.
Has equipment/materials necessary for the type of OSH trainings provided (e.g.
LCD projector, laptop/computer, sample PPE).
LLL.
Has clean and sanitized comfort room.
SIGNATURE

DATE
DOLE OSHC-STO-Tr
Approved by:
NOTICE of Conduct of OSH TRAINING
Training Organization:
Address:
MA. TERESITA S. CUCUECO, M.D.

Executive Director
Date :
Accreditation No.:
Validity:
Contact Person:
May we request for the approval on the conduct of OSH Training specified below.
Title of Training and Specific Topic
Inclusive Dates and Venues
Name & Signature of Assigned Resource Speaker
Name and Signature

Date
Date:
Dear Director Teresita S. Cucueco:
Please be informed of the following changes in the conduct of the abovementioned training as
specified below:
( ) new schedule/date
Title of OSH Training
( ) new venue
New Schedule/Date of
Training
( ) new/additional speakers
New Venue of Training
Name of New/Additional Speakers with

their signature
Name and Signature of Authorized Official

OSH APPLICATION RENEWAL

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TO BE ACCOMPLISHED IN DUPLICATE

NOT FOR SALE and may be REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT

APPLICATION FORM FOR OSH CONSULTANT (NEW)

Please attach your

City Address (Number & Street, Town/City, Province,

Home/ Provincial Address

Co. Tel. No.

WORK EXPERIENCE (Use additional sheet if necessary).

NOT FOR SALE and may be REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT

APPLICATION FORM FOR OSH CONSULTANT (NEW)

9. Proof/s of accomplishment or participation in OSH

OSH RELATED LECTURES/TRAININGS/SEMINARS ATTENDED - As Resource Speaker

NOT FOR SALE and may be REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT

APPLICATION FORM FOR OSH CONSULTANT (NEW)

OSH SKILLS/EXPERTISE/SPECIALIZATION ACQUIRED (Use additional sheet if necessary)

OSH AWARDS/ACHIEVEMENTS/RECOGNITION RECEIVED (Use additional sheet if

OSH EXAMINATIONS/ELIGIBILITIES PASSED

MEMBERSHIPS/AFFILIATIONS RELATED TO OSH

NOT FOR SALE and may be REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT

APPLICATION FORM FOR OSH CONSULTANT (NEW)

CHARACTER REFERENCES (Give at least 3)

I certify that the information stated above is true and correct.

NOT FOR SALE and may be REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT

APPLICATION FORM FOR OSH CONSULTANT (RENEWAL)

Accreditation NO.: __________________

City Address (Number & Street, Town/City, Province,

Home/ Provincial Address

Co. Tel. No.

WORK EXPERIENCE (Use additional sheet if necessary). Please attach

NOT FOR SALE and may be REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT

APPLICATION FORM FOR OSH CONSULTANT (RENEWAL)

Others, specify _________________

NOT FOR SALE and may be REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT

APPLICATION FORM FOR OSH CONSULTANT (RENEWAL)

OSH RELATED LECTURES/TRAININGS/SEMINARS ATTENDED - As Resource Speaker

OSH SKILLS/EXPERTISE/SPECIALIZATION ACQUIRED (Use additional sheet if necessary)

OSH AWARDS/ACHIEVEMENTS/RECOGNITION RECEIVED

OSH EXAMINATIONS/ELIGIBILITIES PASSED (If any).

MEMBERSHIPS/AFFILIATIONS RELATED TO OSH

NOT FOR SALE and may be REPRODUCED

DEPARTMENT OF LABOR AND EMPLOYMENT

APPLICATION FORM FOR OSH CONSULTANT (RENEWAL)

CHARACTER REFERENCES (Give at least 3)

NOT FOR SALE and maybe REPRODUCED

Occupational Safety and Health Center

APPLICATION FORM FOR OSH CONSULTING

Name of Top Company Head

(Signature over printed

NOT FOR SALE and maybe REPRODUCED

Occupational Safety and Health Center

APPLICATION FORM FOR OSH CONSULTING

Staff Please attach your organizational chart

Office Facilities, Equipment and Material and Office Personnel

Meeting or briefing room can accommodate at least 6 persons.

NOT FOR SALE and maybe REPRODUCED