Ble K12pmo - Application Form - V 3 5 - 20170718 PDF

REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF LABOR AND EMPLOYMENT

REGIONAL OFFICE NO. _________
DOLE ADJUSTMENT MEASURES PROGRAM FOR K TO 12 DISPLACED HIGHER EDUCATION INSTITUTION PERSONNEL
REFERENCE NUMBER
K TO 12 DOLE AMP APPLICATION FORM
THIS FORM IS NOT FOR SALE AND CAN BE REPRODUCED. PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE ACCOMPLISHING
THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK OR BLUE INK ONLY. WRITE “N/A”IF NOT APPLICABLE. KDA FORM A (Revised, 18 Sept 2017)
A. APPLICANT INFORMATION
NAME (FIRST NAME) (MIDDLE NAME) (LAST NAME) (SUFFIX) GENDER
Male Female
DATE OF BIRTH (MM/DD/YYYY) AGE PLACE OF BIRTH (CITY/MUNICIPALITY) (PROVINCE) (COUNTRY)
CIVIL STATUS NATIONALITY TELEPHONE NUMBER MOBILE NUMBER EMAIL ADDRESS
PERMANENT ADDRESS (RM./FLR./UNIT NO. & BLDG. NAME) (HOUSE/LOT & BLK. NO.) (STREET NAME) (SUBDIVISION/VILLAGE)
(BARANGAY/DISTRICT) (CITY/MUNICIPALITY) (PROVINCE) ZIP CODE COUNTRY
HAVE YOU REGISTERED IN ANY OF THE DOLE/PESO OFFICES? NO YES ARE YOU A PERSON WITH DISABILITY? NO YES
(IF YES, SPECIFY OFFICE, ADDRESS, AND DATE OF REGISTRATION) _____________________________________ (IF YES, SPECIFY TYPE OF DISABILITY) ________________________
ARE YOU A BENEFICIARY/GRANTEE OF ANY GOVERNMENT MITIGATION PROGRAM? NO YES
(IF YES, SPECIFY IF CHED, DepEd, TESDA, OR OTHER GOVERNMENT AGENCY) _____________________________________
B. EDUCATIONAL BACKGROUND
LEVEL NAME OF SCHOOL COURSE DATE (FROM) DATE (TO) HONORS/AWARDS
ELEMENTARY
SECONDARY
VOCATIONAL
COLLEGE
GRADUATE STUDIES
C. ELIGIBILITY
ELIGIBILITY/LICENSES LICENSE NUMBER EXPIRY DATE
D. TRAINING/SEMINARS/CONFERENCES/WORKSHOPS/SHORT COURSES ATTENDED (START WITH MOST RECENT)

TITLE INCLUSIVE DATES NUMBER OF HOURS CONDUCTED/SPONSORED BY
E. EMPLOYMENT INFORMATION
STATUS OF DISPLACEMENT
Totally Displaced as of (Date) ___________________________________ Partially/Temporarily Displaced as of (Date) ___________________________________
PREVIOUS HEI EMPLOYER (NAME OF INSTITUTION) EMPLOYER’S ADDRESS PREVIOUS POSITION
SALARY (MONTHLY) TYPE OF EMPLOYMENT NATURE OF EMPLOYMENT STATUS OF EMPLOYMENT

Teaching Non-Teaching Full-Time Part-Time Permanent Temporary/Probationary Contractual Casual
OTHER WORK EXPERIENCES (START WITH THE MOST RECENT)
MONTHLY NATURE OF PRIVATE /

INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
SALARY EMPLOYMENT GOVERNMENT
F. LANGUAGE PROFICIENCY
LEVEL OF MASTERY (BASIC, INTERMEDIATE, ADVANCED)
LANGUAGE CERTIFICATION VALIDITY DATE
SPEAKING WRITING
G. TECHNICAL/VOCATIONAL SKILLS
AUTO MECHANIC GARDENING PLUMBING
CARPENTRY HAIRDRESSING TAILORING
COOKING MASONRY WELDING
DRIVING PHOTOGRAPHY OTHERS: _________________________
H. K TO 12 DOLE AMP OFFERED SERVICES (Choose any or all of the following services offered by K to 12 DOLE AMP)
Financial Support
Employment Facilitation
Livelihood Opportunities (DILEEP)
INSTRUCTIONS FOR APPLICATION

1. This form shall be used in applying for K to 12 DOLE AMP.
2. Fill out this form in one (1) copy without erasures and alterations.
3. Place a checkmark on the application box.
4. Always indicate “N/A” or “Not Applicable”, if the required information is not applicable.
5. This form shall be submitted with the following documentary requirements:
a. Certificate of Displacement; or copy of complaint duly received by NLRC in case the beneficiary has filed a case before the NLRC;
b. Certificate of Employment and Compensation; and
c. Any government-issued ID.
6. Applications may be submitted to any DOLE Regional or Field Offices.
Applications submitted to DOLE Field Offices will be forwarded to the nearest DOLE Regional Office for evaluation.
7. All applications will be evaluated within 3 to 5 working days from receipt of complete requirements.
Applicants will be notified on the status of application within 3 working days after evaluation.
8. Approved applicants will receive the following:
a. For approved application of totally displaced HEI personnel, a Notice of Assistance, Beneficiary Progress Report and Initial Beneficiary
Assessment Form;
b. For approved application of partially and temporarily displaced HEI personnel, a Notice of Assistance and Initial Beneficiary Assessment
Form.
9. Approved applications submitted within the fifth day of the reference month shall receive the first tranche of their Financial Support directly to the
beneficiary’s Land Bank of the Philippines account at the end of the reference month. Applications submitted beyond the fifth day of the reference
month will receive the first tranche of the Financial Support on the next schedule of release the following month.
“Notwithstanding the confidentiality of the data that I have supplied herein, I hereby give my consent that the same be secured and accessed
for subsequent validation, verification, and other purposes consistent with the objectives of this application. I have full knowledge and agree
that the cause of my displacement is the implementation of RA 10533, hence this application. I further affirm that by affixing my signature on
this form, all statements/data appearing in this form are true, correct and complete to the best of my knowledge and belief.”
SIGNATURE OF APPLICANT DATE

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REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF LABOR AND EMPLOYMENT

CIVIL STATUS NATIONALITY TELEPHONE NUMBER MOBILE NUMBER EMAIL ADDRESS

(BARANGAY/DISTRICT) (CITY/MUNICIPALITY) (PROVINCE) ZIP CODE COUNTRY

D. TRAINING/SEMINARS/CONFERENCES/WORKSHOPS/SHORT COURSES ATTENDED (START WITH MOST RECENT)

SALARY (MONTHLY) TYPE OF EMPLOYMENT NATURE OF EMPLOYMENT STATUS OF EMPLOYMENT

MONTHLY NATURE OF PRIVATE /

INSTRUCTIONS FOR APPLICATION

SIGNATURE OF APPLICANT DATE

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