Form 2. Medical Examination Application Form
This form is intended for applicants who are in need of undergoing a medical examination for overseas employment.
Email address *
1. Full Name (Last, First Middle) *
Answer in ALL CAPS. EX: DELA CRUZ, JUAN MIGUEL
2. Name of Employer *
Anwser in ALL CAPS. EX: YUJU KAI SOCIAL WELFARE CORPORATION
3. Name of Kumiai *
Anwser in ALL CAPS. EX: J TRADING COOPERATIVE. If not applicable, write N/A.
4. Type *
Choose the correct type. For new applicants, choose TITP i.
5. Current Status *
Choose the correct type. For new applicants, choose pre-qualification.
6. Current Address *
Write in ALL CAPS. EX: 3F DRAGON BLDG., 124B V. LUNA EXT. SIKATUNA VILLAGE, QUEZON CITY
7. Nearest Clinic (Option 1) *
This list is from the POEA/DOLE accredited "LIST OF ACCREDITED MEDICAL FACILITIES FOR OVERSEAS WORKERS AND SEAFARERS" As of June 30, 2019.
8. Nearest Clinic (Option 2) *
This list is from the POEA/DOLE accredited "LIST OF ACCREDITED MEDICAL FACILITIES FOR OVERSEAS WORKERS AND SEAFARERS" As of June 30, 2019.
9. Nearest Clinic (Option 3) *
This list is from the POEA/DOLE accredited "LIST OF ACCREDITED MEDICAL FACILITIES FOR OVERSEAS WORKERS AND SEAFARERS" As of June 30, 2019.
10. Preferred Date for Medical Examination *
MM
/
DD
/
YYYY
11. Applicant's Contact Number *
Write your contact number here.
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