APPLICATION FORM
FOR DOMESTIC/HOUSEHOLD WORKERS
(Please fill-in this form in BLOCK-LETTERS format)
DATE APPLIED
PASSPORT NO.
MAY 04, 2015
EB5045068
MARIE MARSHIA
BRIN
UY
SURNAME
GIVEN NAME
MIDDLE NAME
CITY ADDRESS
19 K-69 COR K-71 KARANGALAN VILLAGE CAINTA
RIZAL
PROVINCIAL ADDRESS
DATE OF BIRTH
ΝΑΤΙΟΝΑLITY
HEIGHT
MAY 6, 1974
FILIPINO
SEX
FEMALE
120LBS
RELIGION
NO. OF
CHILDREN
09158350545
TEL. NO.
PLACE OF BIRTH
WEIGHT
5’7
TEL. NO.
MANILA
CATHOLIC
AGE
THEIR
AGES
3
40
22, 14, 4
FAMILY STATUS
SINGLE
SINGLE
PARENT

MARRIED
SEPARATED
SPOUSE’S NAME
WIDOW
OCCUPATION
BENEFICIARY
ABETT EARL UY LUKBAN
RELATIONSHIP
SON
FATHER’S NAME
NARCISO G. UY JR.
AGE
65
OCCUPATION
RETIRED
MOTHER’S NAME
LEONILA UY
AGE
59
OCCUPATION
SALES AGENT
NO. OF BROTHERS
2
THEIR
AGES
33,24
NO. OF SISTERS
3
THEIR AGES
36,30,23
ACADEMIC QUALIFICATIONS
COURSE(s)
COMPLETED
ΟΝΟΜΑ ΤΟΥ ΣΧΟΛΕΙΟΥ/NAME OF SCHOOL
ELEMENTARY
TOMAS EARNSHAW ELEMENTARY SCHOOL
1981
1987
HIGH SCHOOL
ST. ANN ACADEMY
1987
1991
COLLEGE/COURSE
UNIVERCITY/COURSE
NATIONAL COLLEGE OF BUSINESS & ARTS
1995
2000
GLOBAL CITY INNOVATIVE COLLEGE
JUNE 2005
OCT. 2005
YEAR
FROM
TO
VOCATIONAL
OTHERS
ΕΠΑΓΓΕΛΜΑΤΙΚΗ ΕΜΠΕΙΡΙΑ/WORK EXPERIENCE
(List of all working experience starting from the most recent)
FROM
TO
JAN.20
12
JUNE
2012
(1) NAME OF COMPANY/EMPLOYER/
COUNTRY
AIOS IT SOLUTIONS
POSITION
DUTIES&RESPONSIBILITIES
TECHNICAL
REPRESENTATI
TECHNICAL SUPPORT FOR
EMPLOYEES VIA PHONE OR
1
REMARKS
FROM
AUG.
2011
TO
(2) NAME OF COMPANY/EMPLOYER
JAN.
2012
TELEPERFORMANCE
REMARKS
FROM
NOV.
2002
TO
(3) NAME OF COMPANY/EMPLOYER
AUG.
2008
SPEEDZONE CORP.
VES
SALARY
EMAIL
POSITION
DUTIES&RESPONSIBILITIES
CUSTOMER
SERVICE
REPRESENTAT
IVES
SALARY
INBOUND CUSTOMER SUPPORT
FOR US CREDIT CARD
POSITION
DUTIES&RESPONSIBILITIES
ADMIN
OFFICER
ADMINISTRATIVE AND CLERICAL
REMARKS
PHP. 23,000
PHP. 16,000
PHP. 35,000
SALARY
FROM
JUNE
2001
TO
(4) NAME OF COMPANY/EMPLOYER
AUG.
2002
SAN ISIDRO BARANGAY HALL
POSITION
CLERK
REMARKS
SALARY
DUTIES&RESPONSIBILITIES
PHONE CALLS, ASSIST BRGY.
OFFICIALS, ISSUE PUBLIC
AFORME & PERMITS
PHP. 3,500
State your priority by numbering from 1 to 10, what you do best, second best, etc.
Cooking
7
Baby Care
6
Ironing
Geriatric
Care
4
Gardening
1
0
Laundry
8
Child Care
2
3
Cleaning
5
Tutoring
1
9
Care of Disabled
Languages Spoken
PERSONAL QUESTIONS
(Please read carefully and be honest in giving your answers)
1. Would you be willing to accept the «ΝΟ—DAY-OFF» policy of your employer?
YES
NO
2. Are you willing to accept and take your «DAY-OFF’s» set by your employer?
YES

NO
3. Are you prepared NOT to use the telephone without permission or consent of
your employer?
YES

NO
4. Would you be willing and able to follow the all rules and regulations in the
house set by your employer?
YES

NO
5. Would you promise NOT to invite your friends/relatives in your employer’s
residence without their permission/consent?
YES

NO
6. Do you smoke? If yes, how many cigarettes per day? ___________
YES
7. Do you drink? If yes, is it light? _________moderate? ________heavy? ______
YES
NO



NO
2
8. Have you ever experienced taking drugs before? If yes, please specify what
kind ___________________________
YES
NO

9. Are you under medication? If yes, please specify:________________________
YES
NO

10. Do you have any physical defects/disabilities/sickness? If yes, please
specify:_________________________
YES
NO
11. Have you suffered from any serious illness before? If yes, please specify:
_______________________________
YES
NO
12. Have you undergone any operations for the last twelve (12) months? If yes,
please specify: ___________________
YES
NO
13. Do you suffer from any forms of allergy? If yes, please specify:_____________
YES
NO
14. Would you be willing and/or able to handle taking care of pets? If yes, please
specify: _________________________
YES

NO
15. Can you promise to finish your contract in, say, four (4) years?
YES

NO
16. Can you promise to be good to your employer and/or any immediate
member(s) of his family?
YES

NO
17. Do you promise NOT take any salary advances from your employer, no matter
what the circumstances may be?
YES

NO
18. Do you promise not to run-away from your employer?
YES

NO
19. Can you promise not to go out from your employer’s house without his
permission or consent?
YES

NO
20. Can you promise not to take anything that is not yours, whether or not it is in
your employer’s house or another place of residence or place – and that you
will immediately and honestly report something that you might have found
lying around?
YES

NO




CAN YOU HANDLE THE FOLLOWING? – PLEASE TICK YOUR ANSWERS BELOW
ELECTRICAL HOME APLIANCES
HOUSEHOLD CHORES
BABY/PEDIATRIC CARE
Washing
Machine
Rice
cooker
Dish
Drainer
Vacuum
Cleaner
Floor
polisher
Yes
√
No
Cleaning
Yes
√
No
Bathing
Yes
√
No
Yes
√
No
Washing
Yes
√
No
Yes
√
No
Yes
√
No
Ironing
Yes
√
No
Yes
√
No
Yes
√
No
Cooking
Yes
√
No
Changing
Clothes
Changing
Diapers
Feeding
Yes
√
No
Yes
√
No
Gardening
Yes
√
No
Nurturing
Yes
√
No
Microwave
Oven
Yes
√
No
Yes
√
No
√
No
Yes
√
No
Yes
√
No
Bedtime
Care
Baby
Massage
Yes
Oven
Toaster
Car
Washing
Shopping
Yes
√
No
3
Others:
________
Yes
No
CHILD/INFANT CARE
Others:
________
Yes
No
Others:
________
GERIATRIC/OLD & INVALID CARE
Yes
No
BEDRIDDEN CASES CARE
Bathing
Yes
√
No
Bathing
Yes
No
Bed Bath
Yes
No
Changing
Clothes
Changing
Diapers
Bottle
Feeding
Nurturing
Yes
√
No
Yes
No
Hair
Shampooing
Yes
No
Yes
√
No
Yes
No
No
√
No
Yes
No
Yes
No
Yes
√
No
Yes
No
Changing
Diapers
Tube
Feeding
Nurturing
Yes
Yes
Changing
Clothes
Changing
Diapers
Bottle
Feeding
Nurturing
Yes
No
Bedtime
Care
Others:
________
Yes
√
No
Massaging
Yes
No
Massaging
Yes
No
No
Others:
Yes
No
Others:
________
________
ADDITIONAL PERSONAL QUESTIONS
(please answer them with all honesty)
Yes
No
Yes
Why do you want to work abroad?
TO GIVE MY KIDS AN OPPORTUNITY TO HAVE BETTER FUTURE
a
TO EXPERIENCE LIVING AND WORKING IN A DIFFERENT CULTURE
In your opinion, what are the real qualities of a domestic helper/worker (or caregivers/caretakers)? To your
mind, what are these qualities?
TENDER LOVING CARE, HARDWORK, PATIENCE,INIATIVE
b
What foreign dish(es) Chinese
can you cook?
Can you specify or list any of them?
c
Japanese
Italian
Western
Others
SIMPLE PASTA DISHES, SALAD
Do you know anyone at the country you are going? If yes, please give some details as to their:
Name
Nationality
4
Address
d
Name
Nationality
Address
YOUR PORTRAIT-SIZED PICTURE BELOW
Please write a nice personal note below for
your prospective employer to read about
you:
DEAR SIR/MAM;
I MAY NOT HAVE EXPERIENCE WORKING FOR A
FAMILY AS HOUSEHOLD/NANNY/CAREGIVER BUT I
HAVE 3 KIDS AGED 22, 14, 4. THE ONLY THING I CAN
PROMISE IS GIVE YOUR FAMILY THE SAME I,VE GIVEN
MY OWN FAMILY AND HOME.
DECLARATION:
I hereby affirm that all the information above were true; and
That, I shall undergo the required medical and trade test exams at my own expense;
That, the act of filling of such application and the required travel documents I submitted does not assure an immediate employment
but a mere application for overseas employment;
That, upon acceptance by the employer I shall pay the required placement fee;
That, if I withdraw my application, I shall pay a withdraw fee to cover any and all administrative costs, paper works and tim e
consumed;
That, in three (3) months after my employment, I shall not hold ……………… Agency liable for any violation of my contract of
employment and
That, in any mis-declaration or misinterpretation I may have written/ stated herein can become a just cause for my immediate
dismissal in my employment in the future.
I ALSO HEREBY ATTEST THAT I am aware of the offered salary for the above position as stated above, and that I voluntarily, and on
my own will, will accept the said salary should I be hired.
Date applied:
Signature
INTERVIEWR’S REMARKS
NOT FOR SALE
5