FM-POEA 02-GP-07

Effectivity Date: October 03, 2011

DATE:_____________________

BM EVALUATOR

EVALUATION/
ENCODING

____________
TIME
RECEIVED

THIS FORM IS NOT FOR SALE

DO NOT WRITE ON THIS SPACE

PHILIPPINE OVERSEAS EMPLOYMENT ADMINISTRATION

OVERSEAS WORKERS WELFARE ADMINISTRATION
PHILIPPINE HEALTH INSURANCE CORPORATION

CG No:___________________________
RFP No:___________________________
Assessment No:_____________________
Assessed Amount:___________________
POEA:
__________________
OWWA:
__________________
PHILHEALTH:__________________
PAG-IBIG:
__________________

BALIK-MANGGAGAWA
INFORMATION SHEET

____________
TIME
RELEASED

PERSONAL DATA

(for POEA, OWWA, PhilHealth Use Only)

Name:

______________________________ ______________________________ _______________________________

Family Name (Apelyido)
First Name (Pangalan)
Middle Name (G. Apelyido)
Passport No:____________________________________
M
F
Remarks
Birthdate: _______/_______/________
Civil Status:
_____________________________
MM
DD
YYYY
Single
Widower
Married
Separated _____________________________
Address in the Phils. (Tirahan)__________________________________________________________________________________________
Telephone/Cellphone No. _______________________________________ Email Address:_________________________________________
Name of Spouse (if married):____________________________________ Mothers Full Maiden Name:_____________________________

CONTRACT PARTICULARS OF OFW

Name of Company/Employer:__________________________________________________________________________________________
Address of Employer:_________________________________________________________________________________________________
Jobsite/Country of Destination:_______________________________ Tel. No./Fax No./Email address:_____________________________
Position of OFW:____________________________________________ Contract Duration:________________________________________
Salary:_____________________________________________________ Currency:_______________________________________________
Date of arrival:______________________________________________ Date of departure/Return of OFW to the jobsite:______________

______________________________________________
Workers Signature Over Printed Name

FOR BM GROUP/AGENCY
Name of Agency:_________________________________________________________________________________________
______________________________________________
Approval of Authorized Agency Representative

OWWA

Legal Beneficiaries (Mga tatanggap ng benepisyo)

Name

Relationship

Address

____________________________________

__________________________

_____________________________________

_________________________________________

_____________________________

_________________________________________

PHILHEALTH PORTION

TO BE FILLED OUT BY OFW

Name ______________________________

______________________________

Family Name (Apelyido)

_______________________________

First Name (Pangalan)

Address in the Philippines (Tirahan):

Middle Name (G. Apelyido)

Email Address:_______________________________

___________________________________________________________________ _________________ ______________ _______________

Residential Address

Barangay

Municipality

Province

Date of Birth:____ / ____ / ________

Birthplace:________________________ SSS No._________________________
mm dd
yyyy
Complete Address of Destination (Foreign Country): _____________________________________ \ ________________________________
City
Country
Contract/Work Permit Expiry:________________________________________________________ Contract Duration:________________
Civil Status:
Sex:
Name of Spouse:
Single
Married
Male
Widower
Separated
Female
_____________________________
Dependents (Mga Makikinabang):
Children 20 years olf and below: Parents 60 years old and above, Unemployed Spouse.
(Documents Required: Birth Certificate (Child & Parent); Spouse Marriage Certificate, or Senior Citizens Card.
Name of Legal Dependent

Sex

Relationship of OFW to
Dependent/s

Date of Birth
(mm/dd/yyyy)

I hereby certify that the above statements are true and correct and that the above-named dependents have not been
declared by my spouse/brother/sister.
Workers Signature Over Printed Name

POLO-OWWA
(Riyadh)

RMG 13/5/2013

POLO-OWWA Riyadh Office at the DIPLOMATIC QUARTERS COMPOUND

RMG 13/5/2013

POLO-OWWA Al Khobar Office at the GULF CENTER Corniche

ISSUANCE OF OVERSEAS EMPLOYMENT CERTIFICATES

POLO-OWWA in Riyadh and Alkhobar issue Overseas Employment Certificates (OECs)
to workers going on vacation to the Philippines for their convenience. The OEC is
required to be presented to international ports of exit in the Philippines as proof that the
holder is a bonafide OFW. OEC holders are excempted from paying the travel tax and
the airport terminal fee. The OEC has a 60-day validity.
In applying for the OEC, the worker has to present the following documents to POLO,
namely:
a.
b.
c.

copy of exit/re-entry visa,

copy of passport,
proof of employment such as certificate of employment or company ID issued by
the employer.

Cost of the OEC is Saudi Riyal 9.00.

Cost of OWWA Membership fee is Saudi Riyal 94.00
Cost of Pag-Ibig Membership update is Saudi Riyal 20.00
PHILHEALTH is NOT required.
IMPORTANT POLO CONTACT NUMBERS
Landlines: (01) 483-2201, (01) 483-2202, (01) 483-2203
(01) 483-2204 (fax number)
(01) 481-6448 (Filipino Workers Resource Center-Bahay Kalinga)
POLO Hotline : 00966-545917834
OFFICE HOURS
RIYADH: Saturdays to Wednesdays (8:00 am to 5:00 pm)
KHOBAR: Saturdays and Sundays (10:00 am to 4:00 pm)