DOLE GIP Form A

DOLE REGIONAL OFFICE No. V

Masbate Provincial Field Office
GOVERNMENT INTERNSHIP PROGRAM (GIP) APPLICATION FORM
INSTRUCTION TO APPLICANT: Please fill-out in three (3) copies all the required information in this form and attach additional documents, if necessary.

1. NAME OF APPLICANT:

Family Name First Name Middle Name

2. RESIDENTIAL ADDRESS:
ATTACHED 2 X 2 PHOTO WITH NAME

AND SIGNATURE TAKEN WITHIN THE

LAST THREE (3) MONTHS

Telephone No:

Mobile No:

Email Address:

3. PLACE OF BIRTH (City/Province)

4. DATE OF BIRTH (mm/dd/yyyy) AGE:

5. GENDER Male Female

6. CIVIL STATUS Single Married Widow/Widower

7. LBP ATM ACCOUNT NO.*

8. NAME OF GSIS INSURANCE BENEFICIARY**: RELATIONSHIP:

9. EDUCATIONAL ATTAINMENT
NAME OF SCHOOL INCLUSIVE DATES DEGREE OR DIPLOMA
FROM TO

CERTIFICATION: I certify that all information given in this application are complete and accurate to the best of my knowledge. I acknowledge
that I have completely read and understood the DOLE-GIP Guidelines as embodied in Administrative Order No. 436 Series of 2013.

DATE SIGNATURE OF APPLICANT

FOR DOLE RO/FO Use Only
Interviewed by and validated by:

______________________________________________
NAME and SIGNATURE

______________________________________________ _____________________
Position DATE
DOCUMENTS RECEIVED: (Pls. check)
1. DOLE GIP Form A (3 copies) 3. Birth or Baptismal/Marriage Certificate (3 copies)
2. Any of the following school records (3 copies) 4. Certificate of Indigency (Optional)
Transcript of Records/Form 137 5. ID No.: Date of Issue:
Certificate of Graduation in case of voc-tech or ALS graduates Place of Issue:
College or High School Diploma (3 copies)
* Payment of stipend/allowance shall be through Payment Center
** Interns will be covered by GSIS insurance
 DOLE GIP Form B
A. PLEASE DESCRIBE YOUR CURRENT AREA OF STUDY

B. PLEASE TELL US WHY YOU ARE INTERESTED IN DOLE GIP

CERTIFICATION: I certify that all information given in this application are complete and
accurate to the best of my knowledge. I acknowledge that I have completely read and
understood the DOLE GIP Guidelines as embodied in Administrative Order No. 119 series of
2012

DATE: SIGNATURE OF APPLICANT (required):