STANDARD APPLICATION FORM

I. Applicant Details

*Surname/Family Name *First Name *Middle Name

YU Jessica Rodriguez

Preferred
*Title: Ms. Jessica *Civil Status: Single
Name:

*Country of
*Date of Birth: 11/01/1988 Philippines *Citizenship: Philippines
Birth:

*Have you ever worked abroad (Nursing or non-nursing related)?:

*Previous countries of residence: During the past three years, have you ever
lived outside Philippines?If you answered yes, please provide details below:

II. Contact Details

*Current *Country Philippines

453 Dionesio Village, Barangay Tinampo,
Residence
Palapag, Northern Samar *ZIP Code 6421
Address:

*Permanent Address: (same as current residence address?)

*Email Email Address

[email protected] [email protected]
Address 1: 2:

*Mobile If you are on Landline

09774981894 N/A
Number: WhatsApp? Number:

Facebook Account Name: N/A Skype ID N/A

*Primary Contact Person In

*Relationship *Contact Number
Case of Emergency

Roxan Yu Sister 09155798204

*Address: (same as current residence address?)

Secondary Contact Person In

Relationship Contact Number
Case of Emergency
 N/A N/A N/A

Address: (same as current residence address?)

N/A

III. PASSPORT DETAILS

*Do you have a valid passport?

*Passport Number *Place of Issue: *Issue Date *Expiry Date

EC6942703 DFA TACLOBAN 03/03/2016 02/03/2021

IV. PROFESSIONAL REGULATION COMMISSION (PRC) DETAILS

*Do you have a valid PRC Licence?

*What is your
*Initial Registration
professional *Registration Number *Expiry Date
Date
qualification?

Nurse 0790493 18/02/2013 11/01/2022

V. OTHER REGISTRATION DETAILS

*Do you have any other professional registration?

VI. ENGLISH LANGUAGE TEST

Have you taken any English Language Test?

Type of exam: International English Language Test System

IELTS 1:

Type of
UKVI *Date Taken: 26/07/2019
IELTS:

*TRF #: 19PH006570YUJ001A0 *Expiry Date: 17/07/2021

SCORES

Listening 8 Writing 7 Reading 7

Speaking 7.5 Overall Band Score 7.5

VII. Application Details

*Have you applied to ASC before?:

*Have you completed the POEA online Pre-Employment Orientation Seminar?

*Preferred Area of *Preferred Area of Preferred Area of

Specialization - 1: Specialization - 2: Specialization - 3:

THEATRE / OR GYNAECOLOGY N/A

*Pending Application with other agency(ies):

Have you worked in the UK before?

VIII. EDUCATION DETAILS

*Date
Qualification 1 Bachelor's Degree 12/04/2012
Completed:

Name of
Colegio de San Lorenzo Ruiz de Manila, Inc. *Country: Philippines
Institution

Course Taken: Bachelor of Science in Nursing

IX. EMPLOYMENT HISTORY:

Voluntary Employed
*CURRENT STATUS
Unemployed Training/Education

EMPLOYMENT

*Organization Registered Unregistered

Department of Health
Name: Practice Practice

*Organization
Government Center, Candahug, Palo, Leyte
Address:

*Specialty / Community
*Job Title: Nurse II
Area Nurse

Healthcare
*Start: 17/06/2019 *End: 11/09/2019
Industry:

Company
Private /
Bed Capacity: N/A Government Contact N/A
Government?
Number:
*Description of the role:

- Conducts regular visit to priority households with health problems

- Prepares health status reports of families/households visited
- Plans for appropriate interventions on the identified health concerns of families/households
- Assists in the preparation of Barangay Health Plans
- Supervise, train and orient the CHT/BHWs and conduct regular monitoring and evaluation of
various health programs together with the MHO, PHN and DMO
- Participates in the implementation of health programs of DOH and the LGU in the community
- Assists in the conduct of disease surveillance
- Conducts health education, advocacies and training om different DOH programs
- Prepares reports of home visits, follow up patients, track referrals and community activities
conducted
- Coordinates with the Public Health Associates to ensure timely data collection and reporting
- Assist the MHO and PHN in the conduct of PIR, MDR and Death/Mortality reviews
- Participate in data gathering and response during health emergencies and disasters

EMPLOYMENT GAP

*Start: 01/01/2019 *End: 16/06/2019

Explanation of gap in employment

The passing of 2019 National Budget was delayed so the hiring of hiring of Human Resource for
Health has been postponed until the budget was available.

EMPLOYMENT

*Organization Registered Unregistered

Department of Health
Name: Practice Practice

*Organization
Government Center, Candahug, Palo, Leyte
Address:

*Specialty / Community
*Job Title: Nurse II
Area Nursing

Healthcare
*Start: 01/04/2013 *End: 31/12/2018
Industry:

Company
Private /
Bed Capacity: N/A Government Contact N/A
Government?
Number:
*Description of the role:

- Conducts regular visit to priority households with health problems

- Prepares health status reports of families/households visited
- Plans for appropriate interventions on the identified health concerns of families/households
- Assists in the preparation of Barangay Health Plans
- Supervise, train and orient the CHT/BHWs and conduct regular monitoring and evaluation of
various health programs together with the MHO, PHN and DMO
- Participates in the implementation of health programs of DOH and the LGU in the community
- Assists in the conduct of disease surveillance
- Conducts health education, advocacies and training om different DOH programs
- Prepares reports of home visits, follow up patients, track referrals and community activities
conducted
- Coordinates with the Public Health Associates to ensure timely data collection and reporting
- Assist the MHO and PHN in the conduct of PIR, MDR and Death/Mortality reviews
- Participate in data gathering and response during health emergencies and disasters

EMPLOYMENT GAP

*Start: 18/12/2012 *End: 31/03/2013

Explanation of gap in employment

Waited for the result of Nursing Licensure Examination until it was out by January 31, 2013. After I
passed the exam I registered in the PRC and processed my application with the Department of
Health

STUDY PERIOD

*Start: 01/08/2012
Course Title: Review for Nursing Licensure Examination
*End: 17/12/2012

*Educational or Training Institution Name:

Eastwest Review Center

*Educational or Training Institution Address:

Recto Avenue, Manila

EMPLOYMENT GAP

*Start: 13/04/2012 *End: 31/07/2012

Explanation of gap in employment

Waited for the start of review classes for Nursing Licensure Examination.

STUDY PERIOD

*Start: 16/10/2006
Course Title: Bachelor of Science in Nursing
*End: 12/04/2012

*Educational or Training Institution Name:

Colegio de San Lorenzo Ruiz de Manila, Inc.

*Educational or Training Institution Address:

J.P. Rizal St., Catarman, Northern Samar, Philippines

X. UK REGISTRATION:

*Current Status: To Commence NMC Application

XI. EMPLOYMENT REFERENCE

Provincial DHO
*Name: Dr. Rommel C. Francisco *Job Title:
Officer

*Company Email
Department of Health N/A
Name: Address:

*Company
Provincial Doh Office, Catarman, Northern Samar
Address:

*Contact Contact Contact

09173064736 N/A N/A
Number 1: Number 2: Number 3:

Municipal
*Name: Dr. Delia C. Chy *Job Title:
Health Officer

*Company Email
LGU - Palapag N/A
Name: Address:

*Company
Palapag, Northern Samar
Address:

*Contact Contact Contact

09158734148 N/A N/A
Number 1: Number 2: Number 3:
 Development
*Name: Melchor Gaspar Merida *Job Title: Management
Officer IV

*Company Email
Department of Health N/A
Name: Address:

*Company
Provincial Doh Office, Catarman, Northern Samar
Address:

*Contact Contact Contact

09166504586 N/A N/A
Number 1: Number 2: Number 3:
Confirmation:

I hereby certify that the stated information in this application form is correct. I understand
that any wilfully supplied misinformation/misrepresentation will be a ground for my
disqualification even if I am in receipt of Job Offer by the employer. I further understand that
such acts may lead to my dismissal even after deployment.

Signature Date

_______________________ 11/09/2019

Yu, Jessica

Disclaimer:

This document is ASC Global Recruitment, Inc. PROPRIETARY AND CONFIDENTIAL – for
internal use and distribution only. ASC Global Recruitment reserves the right to modify or
reproduce it in whole and in part.