REPUBLIC OF THE PHILIPPINES )
Cagayan de Oro City ) S.S.
WORKER’s DECLARATION
____________NAME/ NGALAN______________, of legal age, Filipino, single/married and a resident of
I,
__________ ADDRESS/PULOY-ANAN ________, after having been sworn to in accordance with law do hereby
declare:
1. That I am a returning worker (Balik-Mangagawa) working as (position)
TRABAHO/TAHAS for my employer (name of employer)
NGALAN SA AMO/KUMPANYA at (address of employer)
JOBSITE/NASUD GITRABAHUAN;
2. That I have been working for the said employer since TUIG NA NAGSUGOD SA TRABAHO;
3. That my employment condition with my employer is best described as (please check as applicable):
󠆎I am treated well and humanely by my employer, and to the best of my knowledge, no such action or proceeding
for suspension/disqualification has been filed or is pending against my employer before the DMW;
󠇮 I am aware that my employer is suspended/disqualified on the basis of DMW Case No.
____________________ entitled ____________________________________. Despite that, I still would like to be
deployed for the said employer;
󠆎 I have no complaint against my employer and will return to work to finish my Employment Contract or until
terminated at my own risk;
4. That I signed my employment contract on (date) PETSA NGA NAG PERMA KA SA CONTRATA;
5. That said employment contract: (check one)
󠆎 Has been verified /authenticated by the Philippine Labor Office or Migrant Workers Office (MWO) / Embassy /
Consulate on PETSA KANUS.A NA VERIFY ANG CONTRATA under OR No. OR NO./ MAKITA SA RESIBO SA
CONTRATA;
󠆎 Has NOT been verified /authenticated by the Philippine Labor Office / MWO/ Embassy / Consulate because
RASON NGANONG WALA NA VERIFY AND CONTRATA . That, although I understand that verified /
authenticated employment contract is a requirement for me to secure an Overseas Employment Certificate (OEC),
I appeal in earnest with the DMW to admit and consider my employment contract notwithstanding that it is not
verified / authenticated;
6. That I warrant that the employment contract is authentic and I take full responsibility over the same;
7. That I shall not hold the Department of Migrant Workers (DMW) or any of its personnel liable if my employment
contract or any of its provisions proves false or not consistent with the prevailing employment laws, standards and
practices of both the Philippines and the host country;
8. That I undertake to faithfully comply with the requirement of submitting my original employment contract verified /
authenticated by the Philippine Labor Office / MWO/ Embassy / Consulate and I shall submit the same to DMW or
DMW Regional Satellite Office personally or through my authorized representative;
9. That I have fully read and understood the contents of my declaration, and it was sufficiently explained to me by the
DMW personnel that submission of false or fictitious employment contract is a form of misrepresentation which is
a ground for administrative disciplinary action under Sec. 145 of the 2016 POEA Rules and Regulations
Governing the Recruitment and Employment of Landbased Overseas Filipino Workers.
IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ________________, 202_.
NGALAN UG PERMA
Affiant
Passport No. ____________________
Administered before me this this ____ day of ________________, 202_. in the City of Cagayan de Oro,
MIsamis Oriental.
______________________________
Administering Officer
Pursuant to POEA S.O. No. 244 S. 2022
