OSH PRACTITIONER/ DOLE-BWC Please attach your

DEPARTMENT OF LABOR AND CONSULTANT AF-PCN-A1 1” x 1” picture

SC: blue background
EMPLOYMENT APPLICATION FORM Revision Code: 0803-0 SP: red background
Regional Office No. (New Applicant) Page 1 of 3 2 COPIES
________ signed at the back

Instructions:
Fill in all the data needed. Use block/printed letters or use a typewriter. Write N.A. if the blanks are not
Applicable. Please sign in all pages of the form.

I would like to apply for Accreditation as: OSH Consultant

OSH Practitioner

1. PROFILE
Last Name First Name Middle Name Civil Status:
Single Widower/Widow

BLANCO RAYMOND GOMEZ Married Separated

City Address (Number & Street, Town/City, Date of Birth: 05- Citizenship: FILIPINO
Province, Zip Code) 12-1976
Height: 5’5 Religion: CHRISTIAN
168 F MARIANO AVE DELAPAZ PASIG CITY
Home/Provincial Address Weight: 74KG TIN No. : PRC No.(if
Blood Type: A+ 256 613 889 any):
Business Address SSS/GSIS No. Cellular Phone No (if any):
33 2504 550 1 0921 929 0719
UNIT 14 PANILAO ARCADE PILAR BATAAN
Home No.: Co. Tel No.:
047 613 43 56
Nature of Business / Specific Product/ Type of Service : E-mail: [email protected] Fax No.:
TRAINING CENTER
Workplace: Employment Size:
Hazardous Non- MALE: ___10___ FEMALE: _10___ TOTAL : __20___
hazardous

PSIC Code: Region: GEO Code: Zip Code:

2. EDUCATIONAL ATTAINMENT - indicate only tertiary education: Masteral, doctoral. Please attach
photocopy of diploma /transcript of records .
Degree/units Earned School / Address Inclusive dates Awards/ Honors
(Last attended)
AMA Computer College AMA PASIG 1998 May 29TH

Quirino High School Quezon City 1994 March 18th

Delapaz Elem Sch. Delapaz Pasig City 1988 March 24

Type of Professional License received: ____________________
PRC License NO.: ________________ Date Issued: ______________ Validity: ______________

3. WORK EXPERIENCE (Use additional sheet if necessary). Please attach original certificate of employment
and job description duly certified by the Personnel Manager/ employer/or authorized company official
YEARS OF OSH EXPERIENCE using official company letter head; and proof of practice (safety
report/programs prepared/implemented). 11 YEARS OF OSH EXPERIENCE

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 Position Length Company
Inclusive Dates Status of
(From recent to of
Appointment
present) From To service
1. Training
January Avie Training and
Director/Optn Present 60 Regular
2016 Consultancy Services
Manager
2. OSH January
July 2018 7 Project Based Betonbau Phil. Inc.
Practitioner 2018
3. Project HSE August December Project Based
16s Bin Quraya Holdings Inc
Manager 2016 2017 OFW
4. Project HSE November January
3 Project Based SAN R Construction I
Lead 2015 2016
5. Regional
December September Dragados Gulf
Safety 30 Project Based
2013 2015 Construction Ltd.
Assistant
6. HSE
January November
Supervisor / 22 Project Based Tecnicas Reunidas
2012 2013
Trainer
7. HSE January December
35 Project Based Tecnicas Reunidas
Administrator 2009 2011

4. OSH RELATED TRAININGS / SEMINARS ATTENDED ( As Participant ) -. ( Use additional sheet if necessary)
Please attach photocopy of certificate. Original copies of certificates to be presented to authorized
DOLE staff for certification.

No. of Conducted by Venue

Title
Inclusive Dates Hours
(Start from recent to
From To
previous)
Occupational Safety
1. Fire safety Feb 01,
Aug 1 2014 1040 and Health Dubai UAE
Engineering 2015
Environment Council
January 6 January Occupational Safety OSHAcademy
2. OSH Manager 48
2014 12,2014 and Health Manager KSA
January January Occupational Safety OSHAcademy
3. OSH TOT 36
15,2014 17,2014 and Health Trainer KSA
Construction Safety
4. EM 385-1-1 January January OSHAcademy
40 Hazard Awareness for
Construction 19,2014 21,2014 KSA
Contractors
January January Occupational Safety OSHAcademy
5. OSH Specialist 44
23,2014 25,2014 and Health Specialist KSA
January February Occupational Safety OSHAcademy
6. OSH Professional 132
26,2014 10,2014 and Health Professional KSA
February February Occupational Safety OSHAcademy
7. OSH Supervisor 36s
12,2014 15,2014 and Health Supervisor KSA
8. OSH Safety and Health
February February OSHAcademy
Committee/Team 36 Committee/Team
17,2014 20,2014 KSA
Leader Leader
9. OSH Safety and Health
February February OSHAcademy
Committee/Team 32 Committee/ Team
22,2014 24,2014 KSA
Member Member

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 TVE
June July
10. OHSAS 18001 40 Lead Auditor Course International
1530,2017 4,2017
Academy
July
11. IOSH V5.0 July 27,2015 24 IOSH UK OHSEC IOSH
30,2015
Environmental
February February Pollution Control
12. PCO 40 Counselors
7,2017 10,2017 Officers Training Course
INC.
SALUS
May May Basic Occupational
13. BOSH 40 Consultancy
24,2016 27,2016 Safety and Health
Services
August August Construction Occupational ASPREC-
14. COSH 40
9,2016 12,2016 Safety and Health MANALO
July Loss Control SALUS
15. LCM July 21,2014 40
24,2016 Management Consultancy
May 5M
16. SPA April 15,2018 40 Safety Program Audit
6,2018 Consultancy
TOTAL HOURS OF TRAINING ATTENDED 1672 HOURS

5. OSH RELATED LECTURES / SEMINARS /TRAININGS CONDUCTED ( As Resource Speaker ) (Use additional
sheet if necessary ) Please attach photocopy of certificate/recognition received.
1. Title/Topic Inclusive Dates Conducted by
Ven
(Start from From to No. of AVIE TRAINING AND
ue
recent to Hours CONSULTANCY SERVICES
previous)
2. General Safety
Awareness in
General Industry, March 20,2016 8 Bataan Peninsula State University 150
Construction,
Mfg and HIRARC
3. Focus Four In
construction,
Defensive
April 28, 2016 8 Peninsula State University 100
Driving,
Chemical
Handling
4. Principle of
Safety Dec. 2016 8 Bataan Peninsula State University 80
Management
5. General Safety
Awareness in
General Industry, March 24,2017 8 Bataan Peninsula State University 100
Construction,
Mfg and HIRARC
6. Risk
DEP ED Bataan Tomas Pinpin
Management March 21,2017 8 100
Elem Sch.
and Risk Control
7. Working at
Heights and May 01. 2017 8 Bataan Peninsula State University
50
Confined Space
8. Bahay Pag
Babago (brgy
Based Drug
August 31, 2017 8 Balanga City Bataan 25
Rehab Center)
Fire and Hole
Watcher Training
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 9. Bahay Pag
Babago (brgy
Based Drug
Sept 2017 8 Balanga City Bataan 34
Rehab Center)
Fire and Hole
Watcher Training
10. Bahay Pag
Babago (brgy
November 08,
Based Drug
2017 8 Morong Bataan 20
Rehab Center)
Fire and Hole
Watcher Training
11. Emergency
Preparedness,
Chemical
Handling, Slips April 03. 2018 8 Balanga City Public Market 100
Trips and Falls
and Fire
Prevention
12. BMEG Mariveles
Mariveles Bataan R. Blanco
Bataan Safety June 08, 2019 8 45
Instructor
Orientation
13. Security and Avie Training and Consultancy
June 20, 2018 8 100
Safety Services
14. Basic Of Fire
Safety
Engineering,
Chemical June 12, 2018 8 Balanga City Public Market 80
Handling and
Risk
Management
15. DOLE RO 3 -
Tarlac
OSHC RO3 tarcal BOSH Training
Provincial November 6, 2018 8 48
Government
BOSH Training
16. Fire Watcher
and Confined
February 16, 2019 8 YUHANTECH LIMAY 200
Space Entry
Training
17. SOHBI KOHGEI
(Phils.), Inc
ATCS LIPA
Emergency November 10, 2018 8 20
Response
Training
18. Safety Officer 1 April 26, 2019 8 ATCS BATAAN 25
19. Confined
Space Entry ATCS BATAAN
August 03 2019 8 80
Training and YUHANTECH PETRON
Rescue
20. HSE
Documentation
Systems and August 01 2019 8 ATCS BATAAN 65
OHSAS 18001
basics
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 21. United
Auctioneers Inc
Subic – 8hrs
August 27, 2019 8 ATCS OLONGAPO 400
Mandatory
Training for
workers
22. Prime Mix Sta
Rita Pampanga
8hrs Mandatory September 12 2019 8 ATCS PAMPANGA 120
Training for
workers
23. COSH TRAINING April 27 - 28 2018 16 ATCS BATAAN 21
24. COSH TRAINING May 8 2018 8 ATCS BULACAN 9
25. COSH TRAINING June 21 - 22 2018 16 ATCS BATAAN 19
26. COSH TRAINING June 27-28 2018 16 ATCS BULACAN 15
27. COSH TRAINING July 19 - 20 2018 16 ATCS BULACAN 29
28. COSH TRAINING August 9 - 10 2018 16 ATCS BATAAN 10
29. COSH TRAINING Sept 13-14 2018 16 ATCS BATAAN 24
30. COSH TRAINING Sept.27-28 2018 16 ATCS BULACAN 8
31. COSH TRAINING Dec. 14-15 2018 16 ATCS OLONGAPO 11
32. COSH TRAINING Dec. 27-28, 2018 16 ATCS BATAAN 20
33. COSH TRAINING January 12-13 2019 16 ATCS BATANGAS 22
34. COSH TRAINING Jan. 16 & 18 2019 16 ATCS OLONGAPO 15
35. COSH TRAINING Feb. 13 & 15 2019 16 ATCS OLONGAPO 7
36. COSH TRAINING February 17 2019 8 ATCS BATANGAS 21
37. COSH TRAINING February 21 2019 8 ATCS BATAAN 19
38. COSH TRAINING February 22 2019 8 ATCS LAGUNA 24
39. COSH TRAINING March 13 2019 8 ATCS OLONGAPO 13
40. COSH TRAINING March 15 2019 8 ATCS BATANGAS 19
41. COSH TRAINING April 27 - 28 2019 16 ATCS BATAAN 21
42. COSH TRAINING May 7 - 8 2019 8 ATCS BULACAN 9
43. COSH TRAINING June 7 2019 8 ATCS LAGUNA 9
San Miguel Brewery
44. COSH TRAINING AUG 11 12 16 16
Sta Rosa Laguna
45. BOSH TRAINING April 25 2018 8 ATCS BATAAN 18
46. BOSH TRAINING May 3-4 2018 16 ATCS BULACAN 7
47. BOSH TRAINING May 17-18 2018 16 ATCS BATAAN 21
48. BOSH TRAINING June 8 & 10 2018 16 ATCS BULACAN 8
49. BOSH TRAINING June 15 & 17 2018 16 ATCS BATAAN 26
50. BOSH TRAINING July 12 & 13 2018 16 ATCS BATAAN 16
51. BOSH TRAINING August 30 - 31 2018 16 ATCS BATANGAS 7
52. BOSH TRAINING Sept. 6 – 7 2018 16 ATCS BATAAN 23
53. BOSH TRAINING Sept. 19-20 2018 16 ATCS BATAAN 39
54. BOSH TRAINING September 23 2018 8 ATCS BULACAN 6
55. BOSH TRAINING October 24-25 2018 8 ATCS BULACAN 10
56. BOSH TRAINING Nov. 27-28 2018 16 ATCS BULACAN 20

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 57. BOSH TRAINING December 21 2018 8 ATCS OLONGAPO 14
58. BOSH TRAINING Dec. 28-29 2018 16 ATCS BULACAN 7
59. BOSH TRAINING January 10-11 2019 16 ATCA LAGUNA 11
60. BOSH TRAINING Jan 17&20 2019 16 ATCS BATAAN 14
61. BOSH TRAINING Jan. 29&31 2019 16 ATCS BULACAN 28
62. BOSH TRAINING February 6-7 2019 16 ATCS PANGASINAN 28
63. BOSH TRAINING February 14 2019 8 ATCS BATAAN 9
64. BOSH TRAINING March 9 2019 8 ATCS PANGASINAN 16
65. BOSH TRAINING March 14 2019 8 ATCS BATAAN 12
66. BOSH TRAINING April 11 2019 8 ATCS BATAAN 26
67. BOSH TRAINING April 25 2019 8 ATCS BATANGAS 17
68. BOSH TRAINING May 5 2019 8 ATCS TARLAC 23
69. BOSH TRAINING June 13 2019 8 ATCS BATAAN 22
70. COSH TRAINING August 8 – 9 2019 16 ATCS BATANGAS 12
71. COSH TRAINING August 10–11, 2019 16 ATCS LAGUNA 35
72. COSH TRAINING August 21& 23 2019 16 ATCS LAGUNA 9
73. BOSH TRAINING September 8 2019 8 ATCS BATAAN 14
74. COSH TRAINING October 19 2019 8 ATCS LAGUNA 13
75. BOSH TRAINING Oct. 24&27 2019 16 ATCS LAGUNA 17
76. COSH TRAINING Nov. 21&24 2019 16 ATCS LAGUNA 29
77. BOSH TRAINING November 29 2019 8 ATCS LAGUNA 13
78. COSH TRAINING Dec. 17 – 18 2019 16 ATCS LAGUNA 11
79. BOSH TRAINING December 27 2019 8 ATCS LAGUNA 12
80. COSH TRAINING Jan. 18 – 21 2020 16 ATCS LAGUNA 24
81. COSH TRAINING Jan. 22-23 2020 16 ATCS BATANGAS 17
82. BOSH TRAINING Jan. 25 & 28 2020 16 ATCS LAGUNA 12
83. BOSH TRAINING Jan. 29-30 2020 16 ATCS BATANGAS 9
84. COSH TRAINING Feb. 20 – 21 2020 16 ATCS LAGUNA 24
85. COSH TRAINING Feb. 19 & 22 2020 16 ATCS BATANGAS 22
86. BOSH TRAINING Feb. 27 & 29 2020 16 ATCS LAGUNA 10
87. LCM TRAINING March 20 – 21 2018 16 ATCS BATAAN 9
88. LCM TRAINING August 1 - 2 2018 16 ATCS Batangas 11
89. LCM TRAINING March 22 -23 2019 16 ATCS Bataan 8
90. LCM TRAINING April 25 – 26 2019 16 ATCS San Fernando 9
91. LCM TRAINING August 21- 22 2019 16 Qurino Isabela Sams Rock R. 47
1068 3098
TOTAL TRAINING HOURS CONDUCTED TOTAL PARTICIPANTS TRAINED
HOURS PAX

6. OSH SKILLS / EXPERTISE / SPECIALIZATION ACQUIRED (Use additional sheet if necessary)

Years of
Trade / Occupation Field of Expertise Brief Description Experience

HSE Manager Oil and Gas Construction Construction Projects 5

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 Training Director OSH Training DOLE Prescribed Training Etc 5

7. OSH AWARDS / ACHIEVEMENTS /RECOGNITION RECEIVED (Use additional sheet if necessary). Attach
photocopy of certificate of award/recognition

Title Issued by Date Issued

1. Certificate of Recognition in 4 Million
Project Manager - Fahad Al – Qahtani
Safe Man-Hours – TR Petrokemya ABS N/A
E&PM EHSEE Lead PK ABS
Project WITHOUT LOST TIME INCIDENT
2. Certificate of Appreciation in 15
Million Safe Man-Hours – TR Technicas Reunidas Jubail Export
N/A
Petrokemya ABS Project Refinery Project Manager
WITHOUT LOST TIME INCIDENT
3. Certificate of Appreciation in 20 Million
Safe Man-Hours – Jubail Export Refinery SATORP Project Manager – Mustafa
January 15, 2012
Project Salamah
WITHOUT LOST TIME INCIDENT
4. Certificate of Appreciation in HSE
Project Site Manager – Antonio L.
Campaigns & Proactiveness in January 15, 2014
Pizarroso – TR PK ABS Project
Safety Culture
5. Certificate of Appreciation in 2
Million Safe Man-Hours – Technicas Project Site Manager – Antonio L.
April 05 2015
Reunidas Petrokemya ABS Project Pizarroso – TR PK ABS Project
WITHOUT LOST TIME INCIDENT
6. Certificate of Excellence in 2015 EG4
Project Manager - Sherif Abdel Fattah
EORR Project / Turnaround, February 28, 2015
Arafa – Dragados Gulf SABIC
Dragados Gulf Ltd. & SABIC - PMT
7. Certificate of Appreciation in 2015
Project Manager – Ibrahim D. Al-
EG4 DGC EORR Project, Dragados February 28, 2015
Buainain – Dragados Gulf Construction
Gulf Ltd. & SABIC - PMT
8. Certificate of Appreciation in 2015
Project Manager – Ibrahim D. Al-
EG4 DGC EORR Project, Dragados February 28, 2015
Buainain – Dragados Gulf Construction
Gulf Ltd. & SABIC - PMT
9. Certificate of Appreciation BPSU
Bataan Peninsula State University PSME
Safety Seminar BPSU Main Campus, March 26, 2017
BPSU
Balanga City, Bataan
10. Certificate of Recognition in Balanga
City Bahay Pagbabago Confined
Balanga City Mayor - HON. Francis
Space Entry Attendant & Fire September 6, 2017
Anthony S. Garcia
Watcher Attendance at Balanga
City, Bataan
11. Certificate of Appreciation – 8hrs
OSH Orientation United Auctioneers United Auctioneers Inc. Subic 27th August 2019
Inc.
12. Certificate of Recognition Balanga
City Security and Safety Seminar as Balanga City Mayor - HON. Francis
June 20, 2018
Resource Speaker at Balanga City Anthony S. Garcia
Public Market
13. Certificate of Appreciation – 8hrs
United Auctioneers Inc. Subic 26th April 2019
OSH Orientation United Auctioneers
14. 56Nos Certification of Appreciation From March 2016 -
Avie Training and Consultancy Services
see Attached file Present

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 DEPARTMENT OF LABOR OSH PRACTITIONER/CONSULTANT DOLE-BWC
AND EMPLOYMENT APPLICATION FORM AF-PCN-A1
Regional Office No. (New Applicant) Revision Code: 0803-0
______________ Page 3 of 3

8. OSH EXAMINATIONS / ELIGIBILITIES PASSED (if any) (Use additional sheet if necessary). Please attach
photocopy of ID, license or certification
Title Year Taken Given by Rating

LEAD AUDITOR COURSE July 2017 TVE INTERNATIONAL

FIRE SAFETY ENGINEERING AUGUST 2015 OHSEC DUBAI UAR

9. MEMBERSHIPS / AFFILIATIONS RELATED TO OSH

Organization / Institution / Agency Designation / Position Validity

10. CHARACTER REFERENCES (give at least 3)

Name Position / Occupation Company / Address Contact Number/s

Salvacion I Jaro CEO / GM Avie training and Consultancy Services 0995 980 2496
Greco Belgica PACC Commissioner Presidential Anti-Crime Commission (02) 8967-7051
Joseph Elving Santos Corporate Safety Mngr. Amsteel Structures Inc. 0998 588 9203

Do you have any pending a) administrative case Yes No b) criminal case? Yes No

If you have any, give details of the offense _________________________________________________________

Have you been convicted of any crime or violation of any law, decree, ordinance or regulations by any
court or tribunal?

Yes No If yes, give details _________________________________________________________

Have you ever been convicted of any administrative offense? Yes No

If your answer is “YES”, give details of the offense __________________________________________________

Have you ever been retired, forced to resign or dropped from employment in the public and private sector?

Yes No If yes, give reasons __________________________________________________________

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