FM-DOLE RO3-TSSD2-SPES-01

Effectivity: January 03, 2017

Revision No. 2
No. 01081
Processed By:
RYAN JIN D. BUGAY
Name of Student: _____________________________ Name: ___________________________________
Name of Employer: LGU-BALANGA CITY__________ Position:________________________________
Address: __BALANGA CITY, BATAAN____________ Date: ____________________________________

SPES REQUIREMENTS CHECKLIST

PESO FO RO/TSSD2 IMSD AUDIT

1. SPES Application Form

2. Certified True Xerox Copy of any of the
following to attest student's true age:
 Birth Certificate
 Form 138 where age is specified
 Joint affidavit of two (2) disinterested parties as to
the age of student
3. Certified True Xerox Copy of any of the following
to attest student's true rating:
 Form 138
 Certification by the School Registrar that he/she
has obtained a passing grade during the previous
or last semester/school year attended.
 Certified True Xerox Copy of student's class
card/s/Report of Grades of the previous or last
semester/school year attended where the student's
passing grade could be determined.
 Certificate of out-of-school youth (OSY) issued by
the Barangay or Office of the DSWD/MSWD/CSWD
(for OSY)
4. Any of the following to attest to parent's income;

 Certified True Xerox Copy of Latest Income Return

(ITR) duly filed with the Bureau of Internal Revenue
(BIR);
 Certificate of Tax Exemption issued by BIR
including sworn statement of affidavit.
 Certificate of Indigence issued by the
Barangay/CSWD/MSWD
5. Contract of Employment
6. Proof of Employment
 Company Payroll / Certification of Employer/
Terminal Report
7. Proof of Enrollment/Schooling (for submission)
 Official Receipt
 Scholarship Certification
 Others (pls. specify) ________________________

Signature over Printed Name of Evaluator:

__NORIEL D. DACION_______
_____________________ ____________________ ______________________
PESO DOLE - FO RO/TSSD2 RO/Accounting

DOLE-RO3 COMPUTATION
TECHNICAL SERVICES AND SUPPORT DIVISION
______ Days x P _______ x ____% = __________
Date Received: _______________ Time: _______
Signature:_________________________________
Signature over Printed Name

Distribution: Original Copy/ White - Auditor's Copy; Duplicate Copy/Yellow - DOLE/TSSD

Triplicate Copy/Light Green – PESO
NOTE: This also serves as a transmittal of documents being submitted in each of the indicated offices per SPES Beneficiary.
 REPUBLIC OF THE PHILIPPINES
SPES Form 4
Department of Labor and Employment
REGIONAL OFFICE NO. III
Public Employment Service Office

__________________BALANGA CITY____________________
SPECIAL PROGRAM FOR EMPLOYMENT OF STUDENTS No. 01081
(RA 7323, as amended by RA 9547 and 10917)

EMPLOYMENT CONTRACT
This Employment Contract is executed and entered into by and between:

Name of Employer: _________LGU-BALANGA

CITY_____________________________________________________________
Address: _______POBLACION, BALANGA CITY,
BATAAN______________________________________________________
and
Name of SPES Beneficiary : RYAN JIN D. BUGAY
_________________________________________________________________________________
8/20/2002 19 SINGLE
Date of Birth: _________________________________________ Age: ______________ Civil Status:
___________________ Address:Proper, Balanga City, Bataan
Naval St., Cupang
_________________________________________________________________________________________________
_____

who voluntarily bind themselves to the following terms and conditions:

1. That the Employer, in accordance with RA 10917 amending RA 9547 and RA 7323, hereby hires and employs the
SPES beneficiary as ______________________________________________
Peer Facilitator/ Backyard Gardener for a period of ___160_ hours
starting on ______________________________________ until ____________________________________;

2. That the Employer shall pay the SPES beneficiary in cash the equivalent of 60% of the existing minimum wage in
the area of __464.95__ per day for the private sector or the approved ________% of the60applicable hiring rate of
_________ per day for the public sector;
464.95

3. That the employer shall observe its obligations, duties and responsibilities to the student as stipulated in the
Implementing Rules and Regulations of RA 10917 amending RA 9547 and RA 7323; and

4. That the SPES beneficiary, in consideration of the above conditions of employment, hereby binds himself/herself to
perform the tasks/duties assigned to him/her and strictly adhere and observe the rules and regulations and/or
company policies prescribed by the Employer.

IN WITNESS WHEREOF, the parties, having read the provisions of this Employment Contract, hereby affixed our signatures
this _______ day of ____________________________2022
at _________BALANGA CITY, BATAAN___________, Philippines.

RYAN JIN D. BUGAY

______________________________________________ HON. FRANCIS ANTHONY S. GARCIA
______________________________________________
SPES Beneficiary Employer/Authorized Representative
(Signature over Printed Name) (Signature over Printed Name)

PERCIVAL H. BUGAY
Consented: ______________________________________
Parent/Guardian
(Signature over Printed Name)

________NORIEL D. DACION____________________
______________________________________________
Witness/PESO Witness/DOLE FO/PO
(Signature over Printed Name) (Signature over Printed Name)

Note: The employer signatory hereof must have the authority to appoint employees.

Distributions: Original Copy/White – Auditor’s Copy; Duplicate Copy/Yellow – DOLE RO/TSSD; Triplicate Copy/Green – PESO

SPES Form 2-A

REPUBLIC OF THE PHILIPPINES
Department of Labor and Employment
REGIONAL OFFICE NO. III
Public Employment Service Office

______________________BALANGA CITY__________________
SPECIAL PROGRAM FOR EMPLOYMENT OF STUDENTS
(RA 7323, as amended by RA 9547 and 10917)
 NO. 01081

OATH OF UNDERTAKING
RYAN JIN D. BUGAY
I, _____________________________________________________________,19 _______ years of
age, residentCity, Bataan
Naval St., Cupang Proper, Balanga of
_____________________________________________________________________________, as a
SPES beneficiary, do hereby agree and undertake to abide and be bound by the following conditions:

1. That I will enroll in any educational or technological vocational (tech-voc) institution to

pursue and continue my studies;

2. That in the event that I would not be able to enroll, I will inform the DOLE Regional Office
concerned and submit a letter narrating and explaining the reason/s for not being able to
enroll;

3. That anytime, during and after my employment period, I vow to respect the implementers of
SPES, and will not use any profane or disrespectful language/s to any PESO or DOLE staff
and/or personnel relative to the program as beneficiary; and

4. That any deviation of my oath and any fraud or dishonesty in any or all of my declaration in
my application shall be a ground for my disqualification in the future availment of SPES.

Signed this _______ day of ________________________________________ , 20______,

22 in the
City/Municipality of ________________________BALANGA__________________.

RYAN JIN D. BUGAY

____________________________________________
Name & Signature of SPES Beneficiary

Witnessed by: Noted by:

__________NORIEL D. DACION_____________
___________________________________________
Printed Name & Signature Printed Name, Position & Signature
PESO Manager/Staff DOLE-FO Staff

______________________________ ____________________________
Date Date

Distributions: Original Copy/White – Auditor’s Copy; Duplicate Copy/Yellow – DOLE RO/TSSD; Triplicate Copy/Green - PESO

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF LABOR AND EMPLOYMENT SPES Form 2
Regional Office No. III
PUBLIC EMPLOYMENT SERVICE OFFICE

________________________________ BALANGA CITY _____________________________

City/Municipality/Province
SPECIAL PROGRAM FOR EMPLOYMENT OF STUDENTS (SPES)
(RA 7323, as amended by RAs 9547 and 10917)
APPLICATION FORM
Control No.: 289112
SURNAME FIRST NAME MIDDLE NAME GSIS BENEFICIARY/RELATIONSHIP
BUGAY RYAN JIN DIZON PERCIVAL H. BUGAY/FATHER
DATE OF BIRTH: (mm/dd/yyyy) PLACE OF BIRTH: CITIZENSHIP:
8/20/2002 LIMAY FILIPINO Passport Size Picture
CONTACT DETAILS/CELPHONE NO.: EMAIL ADDRESS: (3.5cm x 4.5 cm)
09072173000 [email protected]
SOCIAL MEDIA ACCOUNT (FACEBOOK, TWITTER, INSTAGRAM, ETC.) Ryan Jin Dizon Bugay

STATUS SEX  Student  ALS student

 Single  Married  Widow/er  Separated  Male  Female  out-of-school (OSY)
 With Disability/ies Pls. specify: _____________________________  Victims of Armed Conflict  Rebel Returnee
PRESENT ADDRESS: PERMANENT ADDRESS:
Naval St., Cupang Proper, Balanga City, Bataan Cupang Proper, Balanga City, Bataan
FATHER’S NAME /CONTACT NO.: MOTHER’S MAIDEN NAME/CONTACT NO.:
PERCIVAL H. BUGAY/09456239377 CATHERINE L. DIZON/09454135594
OCCUPATION: DRIVER OCCUPATION: CLERK
CURRENT STATUS OF PARENTS:  Living together  Separated  Widow/er
PARENT’S CLASSIFICATION :  Sugar Plantation Worker  Indigenous People  4Ps Beneficiary  Solo Parent
 Person With Disability  Senior Citizen  Displaced Worker (1) __ Local (2) __ OFW  Rebel Returnee
EDUCATION NAME OF SCHOOL SHS TRACK / COURSE YEAR/LEVEL DATE OF ATTENDANCE
Elementary
Secondary Bataan Peninsula State University STEM Grade 12 2021-2022
Tertiary
Tech-Voc
Are you graduating from senior high school / college / technical vocational course next school year?  Yes  No

DOCUMENTARY REQUIREMENTS: (Original and other documents, when applicable, should be presented for validation)

[ ] 1) Photocopy of Birth Certificate or any document indicating date of birth or age (age must be 15-30)
[ ] 2) Photocopy of the latest Income Tax Return (ITR) of parents/legal guardian OR certification issued by BIR that the
Parents/guardians are exempted from payment of tax OR original Certificate of Indigence OR original Certificate of Low Income issued by
the Barangay / DSWD or CSWD where the applicant resides; and
[ ] 3) For students, any of the following, in addition to requirements no. 1 and 2:
[ ] a) Photocopy of proof of average passing grade such as (1) class card or (2) Form 138 of the previous semester or year
immediately preceding the application; OR
[ ] b) Original copy of Certification by the School Registrar as to passing grade immediately preceding semester/year
if grades are not yet available
[ ] 4) For Out of School Youth (OSY), original copy of Certification as OSY issued by DSWD/CSWD or the authorized Barangay Official where
the OSY resides, in addition to requirements no. 1 and 2.
SPECIAL SKILLS:
HISTORY of SPES Availment/ Name of Establishment YEAR SPES ID NO. (if applicable)
[ ] 1stAvailment
[ ] 2ndAvailment-
[ ] 3rdAvailment
[ ] 4thAvailment
Other related information/ requests/ interventions from DOLE:
I hereby attest that the information above are true and correct to the best of my knowledge, including the attached documents / requirements
which I also attest as to their veracity. I agree that any false statement would cause the automatic disqualification/ cancellation of the service/
contract/ grant and I shall refund amount received and/or pay damages to DOLE or comply with other sanctions in accordance with law. Any
material change in my financial status may affect my eligibility to continue the program.

_________________________ ____________________________________
Date Signature of Applicant
___________NORIEL D. DACION______________
Name & Signature of Registration Officer

BLE Revision as of December 2016

Distributions: Original Copy/White – Auditor’s Copy; Duplicate Copy/Yellow – DOLE RO/TSSD; Triplicate Copy/Green - PESO