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Department of Labor and Employment: Republic of The Philippines Intramuros, Manila
Department of Labor and Employment: Republic of The Philippines Intramuros, Manila
Instructions:
1. Accomplish this form in two copies when filing a notice of: a) Flexible Work Arrangement or b) Temporary Closure.
The report is considered as duly filed when the complete list of workers affected is made part of the submission.
2. This form should be submitted to the DOLE Regional/Provincial/Field Office at least thirty (30) calendar days prior to
the effectivity of temporary closure or at least one (1) week prior to the implementation of FWA.
3. Page 1 should contain general information about the establishment and the number of workers affected.
4. Page 2 should enumerate the names of workers affected, their addresses and contact numbers, position title and
salary.
5. Total number of workers listed should equal the total number of workers affected as reported in this page.
A. Establishment Data
CERTIFICATION
This is to certify as to the accuracy of the data provided in this report.
Name and Signature of Owner/Company Representative:
VARGAS, ROY, M.
Employment
Name of Worker Contact Status
No. Age Sex Home Address Designation Salary1
(Last Name, First Name, M.I.) Number (regular,
contractual, etc.)
1 VARGAS, ROY, M 40 MALE Brgy. 1, Alaminos, Laguna 09091166588 Foreman 600/day
Contractual
2 RAPACON, LEOWELL JOHN, G. 40 MALE Brgy. 1, Alaminos, Laguna 09153736707 Staff Contractual 450/day
3 ENRIQUEZ, RONNEL, P 49 MALE Brgy. 1, Alaminos, Laguna 09676025686 Painter Contractual 450/day
4 VARGAS, JERRY, E. 53 MALE Purok 3, San Carlos, Lipa City 09157339747 Painter Contractual 450/day
5
VARGAS, RENCY, E. 30 MALE Purok 3, San Carlos, Lipa City 09276664054 Painter Contractual 450/day
6 SISTINA, ERNIE, B. 53 MALE Purok 3, San Carlos, Lipa City 09104889065 Welder Contractual 550/day
7
ARCILLA, JASPER, V. 27 MALE Purok 3, San Carlos, Lipa City 09294733448 Painter Contractual 450/day
8 BUENO, JESUS JR, B. 24 MALE Purok 3, San Carlos, Lipa City 09515494149 Painter Contractual 450/day
9 DEL CARMEN, JORGE, T. 39 MALE Agusan Del Sur 09091166588 Labor Contractual 400/day
10 HUSAIN, MICHAEL, A. 27 MALE Agusan Del Sur 09157339747 Painter Contractual 450/day
11 CALDERON, LEONARD, J. 20 MALE Agusan Del Sur 09157339747 Labor Contractual 400/day
12 DAGUIL, ROBERT, R. 27 MALE Agusan Del Sur 09157339747 Mason Contractual 500/day
16 DAQUIL, ROMEL, R. 40 MALE Agusan Del Sur 09989546707 Mason Contractual 500/day
17 DAQUIL, RONNEL R. 38 MALE Agusan Del Sur 09989546707 Mason Contractual 500/day
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1
Indicate whether per hour, per day or per month