DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH

REGIONAL OFFICE IV-A REGIONAL OFFICE IV-A REGIONAL OFFICE IV-A

HUMAN RESOURCE FOR HEALTH DEPLOYMENT PROGRAM HUMAN RESOURCE FOR HEALTH DEPLOYMENT PROGRAM HUMAN RESOURCE FOR HEALTH DEPLOYMENT PROGRAM

REQUISITION FORM REQUISITION FORM REQUISITION FORM

PROGRAM PROGRAM PROGRAM
DATE: DATE: DATE:
/ PROJECT: / PROJECT: / PROJECT:
NAME: NAME: NAME:

AREA OF ASSIGNMENT AREA OF ASSIGNMENT AREA OF ASSIGNMENT

MUN. / MUN. / MUN. /
PROVINCE: PROVINCE: PROVINCE:
CITY: CITY: CITY:
COMPLIED COMPLIED COMPLIED
REQUESTS AND REQUIREMENTS REMARKS REQUESTS AND REQUIREMENTS REMARKS REQUESTS AND REQUIREMENTS REMARKS
YES NO YES NO YES NO
CERTIFICATE OF EMPLOYMENT (CURRENTLY EMPLOYED) CERTIFICATE OF EMPLOYMENT (CURRENTLY EMPLOYED) CERTIFICATE OF EMPLOYMENT (CURRENTLY EMPLOYED)
1. Request letter from HRH 1. Request letter from HRH 1. Request letter from HRH
2. COE request form w/ PHTO endorsement 2. COE request form w/ PHTO endorsement 2. COE request form w/ PHTO endorsement
CERTIFICATE OF EMPLOYMENT AND COMPLETION CERTIFICATE OF EMPLOYMENT AND COMPLETION CERTIFICATE OF EMPLOYMENT AND COMPLETION
1. Request letter from HRH 1. Request letter from HRH 1. Request letter from HRH
2. COE request form w/ PHTO endorsement 2. COE request form w/ PHTO endorsement 2. COE request form w/ PHTO endorsement
3. Clearance (see requirements for clearance) 3. Clearance (see requirements for clearance) 3. Clearance (see requirements for clearance)

PAYSLIP PAYSLIP PAYSLIP

1. Request letter from HRH 1. Request letter from HRH 1. Request letter from HRH

INCOME TAX RETURN INCOME TAX RETURN INCOME TAX RETURN

1. Request letter from HRH 1. Request letter from HRH 1. Request letter from HRH

PHILHEALTH CERTIFICATION PHILHEALTH CERTIFICATION PHILHEALTH CERTIFICATION

1. Request letter from HRH 1. Request letter from HRH 1. Request letter from HRH

TIN TIN TIN

1. Request letter from HRH 1. Request letter from HRH 1. Request letter from HRH
2. BIR Form 1902 2. BIR Form 1902 2. BIR Form 1902
3. Birth certificate of dependent/s 3. Birth certificate of dependent/s 3. Birth certificate of dependent/s
(if applicable) (if applicable) (if applicable)
4. Marriage Contract (if applicable) 4. Marriage Contract (if applicable) 4. Marriage Contract (if applicable)
5. Waiver from husband (if applicable) 5. Waiver from husband (if applicable) 5. Waiver from husband (if applicable)

CLEARANCE (Resigned or End of Contract) CLEARANCE (Resigned or End of Contract) CLEARANCE (Resigned or End of Contract)
1. Clearance from LGU 1. Clearance from LGU 1. Clearance from LGU
2. Accomplished ROIV-A Clearance Form 2. Accomplished ROIV-A Clearance Form 2. Accomplished ROIV-A Clearance Form
for HRH for HRH for HRH

REVIEWED BY REVIEWED BY REVIEWED BY

DATE: DATE: DATE:
PHTO STAFF/AO I: PHTO STAFF/AO I: PHTO STAFF/AO I:
RECEIVED BY RECEIVED BY RECEIVED BY
DATE: DATE: DATE:
HRDS/HRMD: HRDS/HRMD: HRDS/HRMD:
HRH DEPLOYMENT FORM 1 HRH DEPLOYMENT FORM 1 HRH DEPLOYMENT FORM 1
Effective: February 2017 Effective: February 2017 Effective: February 2017