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License No. POEA-223-LB-110411-R [pic] Room 300, No. 610 Gochangco Bldg., T.M. Kalaw Street, cor. M.Y. Orosa Street, Ermita Manila, 1000 Philippines t : +63 (2) 524 4745, 524 4750 536 4452, 302 7101 (loc. 201-205) f : +63 (2) 302 7036 e : applymsd@e-recruitment.com.ph w : www.lbsrecruitment.com.ph

We do it better.

APPLICATION FORM

Position Applied Medical Assistant Nurse

Control No. 2014-001-0037119 Your Desired Salary

How did you know LBS Recruitment Solutions Corp.? online/ friends

Do you have any pending application from other Agency / Company? no

Personal Information

| Dela Roca | Miriam | Montalbo |Date Applied | July 25, 2014 |
|Last Name |First Name |Middle Name |Religion | Roman catholic |
|Highest Education | College |Date of Birth| October 2, 1991 |Place of Birth | Batangas City |
|No. of Experience Local | |Abroad | |Age | 22 |
|Civil Status | Single |No. of Children | |Gender M / F |Weight (kg) | 59 |Height (cm) | 162.5 |
|Name of Father | Freddie dela Roca |Occupation | Welder |Date of Birth | September 14, 1967 |
|Name of Mother | Rosita dela Roca |Occupation | housewife |Date of Birth | June 10, 1970 |
|Name of Spouse | |Occupation | |Date of Birth | |

Contact Information

|Primary Address | #246 Gumamela St. Malitam Batangas City |Home Phone | |
| |Postal Code | |Mobile Phone | 09158811919 |
|Provincial Address | Batangas City |Provincial Phone | |
| |Postal Code | 4200 |Office Phone | |
| | | | | |
| | |Skype Account | | |
| | | |
|E-mail Address miriamdelaroca50@yahoo.com | | |
| | | |

Person to Contact in Case of Urgent Message

|Name | Rosita dela Roca |Relationship | mother |
|Address | Malitam Batangas City |Postal Code | |Mobile Phone | 09158811919 |
|E-mail Address / Skype Account | miriamdelaroca |Home Phone | |

If Currently Employed

|Company | |Postal Code | |
|Address | |Mobile Phone | |
|Website / E-mail Address | |Office Phone | |

Educational Attainment

| |Name of School |City/Province |Year Started |Year Finished |Degree / Course |
| | | |(YYYY) |(YYYY) | |
|High School | University of Batangas | Batangas | 2004 | 2008 | |
|College | Lyceum of the Philippines | Batangas | 2008 | 2012 | BS in Nursing |
| |University Batangas | | | | |
|Technical | | | | | |
|Vocational | | | | | |
|Post Graduate | | | | | |
| | | | | | |
| |Number | | | | |
| | |Registration Date |Expiry Date |Place of Issuance |Rating % |
|PRC License | | | | | |

| |Number |Category |Expiry Date |
|Saudi Council Health Specialist (for ex-KSA) | | | |

[pic] Work Experience (Present to Previous)

|Company Name | |Agency | |
|Company Address | |Date Joined (MM/DD/YYYY) |Date Left (MM/DD/YYYY) |
|Number of Beds | |Patient Ratio | | | |
|Hospital Classification | |Salary | |
|Position & Area of Specialty | |Reason for Leaving | |

|Company Name | |Agency | |
|Company Address | |Date Joined (MM/DD/YYYY) |Date Left (MM/DD/YYYY) |
|Number of Beds | |Patient Ratio | | | |
|Hospital Classification | |Salary | |
|Position & Area of Specialty | |Reason for Leaving | |

|Company Name | |Agency | |
|Company Address | |Date Joined (MM/DD/YYYY) |Date Left (MM/DD/YYYY) |
|Number of Beds | |Patient Ratio | | | |
|Hospital Classification | |Salary | |
|Position & Area of Specialty | |Reason for Leaving | |

|Company Name | |Agency | |
|Company Address | |Date Joined (MM/DD/YYYY) |Date Left (MM/DD/YYYY) |
|Number of Beds | |Patient Ratio | | | |
|Hospital Classification | |Salary | |
|Position & Area of Specialty | |Reason for Leaving | |

Other Information

|Special Skills | perform routine clerical and clinical duties in order to maintain efficiency in offices of physicians |
|Computer Application Software you can Operate | |
|Equipment & Medical Instruments you can Operate | |
|List of Language you Speak | English/Tagalog |
|Trainings & Seminars | ELI LILLY NURSE EDUCATION PROGRAM ON DIABETES |
|Basic Life Support / Basic Cardiac Life Support |/Yes No |Date Issued | 2010 |Date Expired | |
|Membership / Affiliation | Volunteer Nurse in Redcross Batangas Chapter |

| |Number |Date of Issued |Expiry Date |Place of Issuance |
|Passport | EB9935521 | January 8, 2014 | January 7, 2019 | DFA Batangas |
|NBI Clearance No. | 18425677 | Dec. 10, 2013 | Dec. 10, 2014 | Batangas City |
|GSIS / SSS No. | |TIN | |Philhealth No. | |

"I, Miriam Montalbo dela Roca, hereby state that I am applying with LBS Recruitment Solutions Corporation to work as Medical assistant Nurse in King Faisal Hospital in Riyadh Saudi Arabia. I hereby certify and attest that: (1) all of the information given above and in the documents I have submitted as of this date are true and correct; (2) all of the documents I have submitted as of this date are genuine and authentic; and (3) all of the information and documents I will give in the future shall also be true, correct, genuine and authentic. In the event that this certification and attestation and any of the information and documents I have given and will give turn out to be false or falsified, I know and accept that I can be subjected to disciplinary/legal action, such as, but not limited to: rejection/denial of application; cancellation/ revocation of job offer, employment contract and/or visa; termination from employment; repatriation; and possible administrative, criminal and civil liability." July 26, 2014 Miriam Montalbo dela Roca Date * LBS RECRUITMENT SOLUTIONS CORPORATION APPLICATION FORM
Signature of Applicant
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