OSH PRACTITIONER/ DOLE-BWC Please attach your

DEPARTMENT OF LABOR AND EMPLOYMENT 1” x 1” picture

Regional Office No. ________ CONSULTANT AF-PCN-A1 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

OSH Practitioner
1. PROFILE
Last Name First Name Middle Name Sex: Civil Status:
Single Widower/Widow
JULIANES PRIMO REGINALES M F
Married Separated
City Address (Number & Street, Town/City, Province, Zip Code) Date of Birth: Feb. 09, 1973 Citizenship: Filipino
Blk69 L20 Mabuhay Homes 2000 Salawag, Dasmariñas City
Cavite 4114 Height: 5’ 6” Religion: Roman Catholic

Home/Provincial Address Weight: 60 Kgs. TIN No. : PRC No.(if any):

Blk69 L20 Mabuhay Homes 2000 Salawag, Dasmariñas City
Blood Type: O
Cavite 4114
Business Address SSS/GSIS No. Cellular Phone No (if any):
2nd Flr. Highway 54 Plaza, 1550, 986 Epifanio de los 09483227872
Santos Ave, Mandaluyong, 1555 Metro Manila Home No.: (046) Co. Tel No.:

Nature of Business / Specific Product/ Type of Service : E-mail: primo_julianes@yahoo.com Fax No.: N.A.
Construction
Workplace: Employment Size:
Hazardous Non-hazardous MALE: ______ FEMALE: _____ TOTAL : _____

PSIC Code: Region: GEO Code: Zip Code:

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)
Bachelor of Science in Mechanical Camarines Sur Polytechnic Colleges June 2002 –
N.A.
Engineering March 2007
N.A. N.A. N.A. N.A.
N.A. N.A. N.A. N.A.
Type of Professional License received: ____________________
Mechanical Engineer
PRC License NO.: ________________ Date Issued: ______________ Validity: ______________

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
3.6
using official company letter head; and proof of practice (safety report/programs prepared/implemented). EXPERIENCE
Position Company
Inclusive Dates Status of
(From recent to Length
Appointment
present) From To of service
Safety Officer 3/20/2018 Present 7 months Project Base Sta Clara International Corporation
Safety Advisor 4/27/2013 7/28/2016 3 yrs Contractual Spacemaker Saudi Arabia LLC
QA/QC Engineer 3/1/2011 3/17/2013 2 Yrs Contractual Refrigeration House Group
QC Inspector 11/22/2006 5/30/2009 2.5 Yrs Contractual Wafer Technology Corp.
PES Supervisor 4/16/2001 12/26/2005 4.6 Yrs Regular Dai-Ichi Electronics Mfg. Corp.

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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
Regional Office No. ___________
DOLE-BWC
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 Inclusive Dates Hours
(Start from recent to previous) From To

ECC Building
Employees’ Compensation Stella Sepagan-
10/10/2018 10/10/2018 5 Gil Puyat,
Program Banawis
Makati City
Loss Control Management 9/22/2018 9/30/2018 40 Dexter P. Mendoza Makati City
Construction Occupational Safety Mandaluyong
2/3/2018 2/11/2018 40 Carlos C. Catane Jr.
and Health City
Occupational Safety and Health Arabian Safety
1/31/2014 2/14/2014 30 Al-Khobar, KSA
Administration Training Center
Risk Management Process 5/13/2016 5/13/2016 4 Alan D. Avellana Al-Khobar, KSA

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 Inclusive Dates Hours
(Start from recent to previous) From To

Accident Investigation & Gen. T. de

10/19/2018 10/19/2018 N.A Primo R. Julianes
Reporting Leon, Val City
Gen. T. de
Risk Assessment 9/14/2018 9/14/2018 N.A Primo R. Julianes
Leon, Val City
Fire Safety Awareness 2/8/2015 2/8/2015 N.A Primo R. Julianes Dammam, KSA
5’S Orientation 11/18/2913 11/18/2013 N.A Primo R. Julianes Dammam, KSA

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

Years of
Trade / Occupation Field of Expertise Brief Description
Experience
N.A. N.A. N.A. N.A.
N.A. N.A. N.A. N.A.
N.A. N.A. N.A. N.A.

7. OSH AWARDS / ACHIEVEMENTS /RECOGNITION RECEIVED (Use additional sheet if necessary). Attach
photocopy of certificate of award/recognition

Title Issued by Date Issued

N.A. N.A. N.A.
N.A. N.A. N.A.
N.A. N.A. N.A.

25
To be accomplished in duplicate Note: This form is NOT FOR SALE. It may be reproduced
 DEPARTMENT OF LABOR AND EMPLOYMENT
Regional Office No. ______________ OSH PRACTITIONER/CONSULTANT DOLE-BWC
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
N.A. N.A. N.A. N.A.
N.A. N.A. N.A. N.A.

9. MEMBERSHIPS / AFFILIATIONS RELATED TO OSH

Organization / Institution / Agency Designation / Position Validity

Philippine Society of Safety Practitioner Interim Member 2016

N.A. N.A. N.A.

N.A. N.A. N.A.

10. CHARACTER REFERENCES ( give at least 3)

Name Position / Occupation Company / Address Contact Number/s

Zambri A, Baya ESH Head Sta Clara International Corp.
Raul Piramide Construction Manager Sta Clara International Corp.
Enrique Abao Safety Supervisor Spacemaker Saudi Arabia LLC

Do you have any pending a) administrative case Yes No b) criminal case? Yes No

N.A.
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 No N.A.
If yes, give details _________________________________________________________

Have you ever been convicted of any administrative offense? Yes No

N.A.
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 No N.A.
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