Republic of the Philippines BLEC - GIP

CITY OF VALENZUELA REFERRAL FORM NO. 1

Metropolitan Manila

BARANGAY LABOR AND EMPLOYMENT COMMITTEE (BLEC)

FOR REFERRAL TO WORKER’S AFFAIRS OFFICE (WAO)

Reference No.: _______________________

Name of Requesting Party for Counseling: Name of Company:

(Pangalan)

Pls. check () Male  Female  Contact Person:

Union  Company  (Pangalan ng TaongKakausapinsaKumpanya)

Address: Position:
(Tirahan) (Katungkulan)

Tel./Cel./Fax./Email Address:
(Tirahan)

Date of Employment: Tel./Cel./Fax./Email:

(Kailannapasoksatrabaho)

Years of Service:
(TaonsaSerbisyo)

Nature of work:
(Trabaho)

CLAIMS/ISSUES RELIEF PRAYED FOR

(Please check the appropriate box/es) (Ano ang gusto niyongsolusyonsareklamo o problema?)

 Payment of Money Claims

a.  Money claims
 Reinstatement
Non-payment/underpayment of
 Cessation of ULP Acts
1.  Wage
 Restitution/Correction of
2.  Overtime Pay
violations of Occupational Safety
3.  Night Shift Differential Pay
and Health Standards
4.  Service Incentive Leave
 Conduct of Election of Union
5. Holiday Pay
Funds
6.  SSS
 Audit/Examination of Union
7. Philhealth
Funds
8.  Pag-IBIG
 Others (Please Specify)
b. Unfair Labor Practice (ULP)
c.  Illegal Dismissal ACTION TAKEN
d. Illegal Dismissal with Money Claims (To be filled-out by BLEC Desk Officer)
e. Non-compliance with Occupational Health and
SafetyStandards  Advice and Counseling
f.  Certification Election Dispute  Referral to WAO
g.  Inter/Intra Union Dispute  For SENA
h.Cancellation of Union Registration Referral No. ______________
i.  Others (Please Specify
REMARKS:

____________________________ ____________________________
Requesting Party’s Signature BLEC Desk Officer – GIP
(Signature over Printed Name)