THIS FORM IS NOT FOR SALE FM-MPC-OIS-D01
REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF LABOR AND EMPLOYMENT
OVERSEAS WORKERS WELFARE ADMINISTRATION
Please fill-out this form legibly. FOR OWWA USE ONLY:
LAST PAYMENT OF OWWA CONTRIBUTION
OFW INFORMATION SHEET OR Number: ______________________________
OR Date: _________________________________
Validity: _________________________________
May 12, 2025
Date:______________________ Verified by: _______________________________
PERSONAL DATA
Adriano Melanie Mata
Last Name First Name Name Ext. (e.g. Jr., III) Middle Name
Philippine Address:
Phase 2 Blk 11 Lot 46 Camellla Homes
House No. Lot No. Block No. Phase No. Street Subdivision
Maliwalo Tarlac City Tarlac 2300
Barangay Municipality/City Province Zipcode
09674096034 lhaniecute19@gmail.co
Contact No.: ______________________ E-mail Address: ___________________________ Passport No.: ______________________
P6204782A
19 83 Sex: ___________________
Birthdate: ___/____/____ Female Catholic
Religion: __________________ Single
Civil Status: _______________________
College Graduate Bachelor of Elementary Education
Highest Educational Attainment: ________________________________ Course: _________________________________________
CONTRACT PARTICULARS
AbdulFattah Abdullah H Al-Saffar
Name of Company/Employer: ___________________________________________________________________________________
Al Hilal Doha
Address: ____________________________________________________________________________________________________
+97477067833 Qatar
Tel No.: _______________________ Jobsite/Country:_______________________________________________________________
Driver
Position: _______________________ 2500
Monthly Salary/Currency: _____________________ Work Visa Year
Contract Duration: __________________
Rite Merit
Name of Agency (if applicable): __________________________________________________________________________________
LEGAL BENEFICIARIES/QUALIFIED DEPENDENTS
Name Relationship Date of Birth Address Contact No./E-mail Address
Milagros Adriano Mother 04/09/53 Tarlac City
__________________________ ______________ _____________ ___________________________ ____________________
09277129474
Orlando Adriano Sr Father 04/15/49 Tarlac City
__________________________ ______________ _____________ ___________________________ ____________________
09954191809
__________________________ ______________ _____________ ___________________________ ____________________
I hereby certify that the above information is true and correct.
Signature of Worker
OWWA Center, 7th St. cor. F.B. Harrison, Pasay City 1300, Philippines . Tel No. 891-7601 to 24 Fax: 804-0638
24/7 Operation Center - Hotlines: 551-6641; 551-1560 . Website: www.owwa.gov.ph
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