Effective: December 21, 2018

DEPARTMENT OF LABOR AND EMPLOYMENT

REGISTRATION FORM
Training Title
Date
Venue

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Participant’s Details
Name:
Last Name First Name Middle Name Suffix (e.g. Jr., Sr., III) Nickname
Date of Birth: Mobile No.:

Company Name:

Position: Department/Section:

Company Address:
street Province

Region ZpCode

Company Contact No./s: Email Address:

Company Website: Industry Type: Total No. of Workers:

For PRC Licensees only
Profession: License Number:

Consent
By filling out this form and signing below, I am giving my consent to the Occupational Safety
and Health Center(OSHCJ to co//ect, process, retain, and store my personal data in accordance with
the provisions of /tepu6/ie Act 10J73 - Data Privacy Act of 20M.
I further give my consent for the video recording of the conduct of training.

Signature over Printed Name

For OSHC use only

Payment:
a Full Date: a Partial Date:
(AfTlOUftE)

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