EMPLOYMENT APPLICATION FORM

POSITION APPLIED FOR :

Staff Nurse / Nurse training officer

SOURCE : (Please check)

Job Ad

Walk-in

EXPECTED SA
School

Referral

Others

PERSONAL INFORMATION
FULL NAME : ( Last Name, First Name, Middle Name)

NICKNAME :

Mortera, Bryan Florentino Mota IV

CURRENT ADDRESS : (No. Street, Town / Locality, City / Province, Zip Code)

#341 San Jose Gusu, Zamboanga City, Zamboanga del sur 7000
PERMANANT ADDRESS : (No. Street, Town / Locality, City / Province, Zip Code)

#341 San Jose Gusu, Zamboanga City, Zamboanga del sur 7000
TELEPHONE NUMBER :

MOBILE NUMBER :

983-0713

EMAIL ADDRESS :

bryan.mortera@yahoo

9175082475

CIVIL STATUS : (Please check Appropriate Box)

Single

Married

IF MARRIED :

Widowed

BIRTH DATE : (mm-dd-yyyy)

5/24/1984

Single-parent

Date of Marriage: N/A

PHILHEALTH NO. :

5'7

BLOOD TYPE :

87

PAG-IBIG NO. :

14-050161575-3

34-5723415-4
WEIGHT :(kgs)

GENDER :

31

SSS NO :

1810203

Plac

AGE :

Malate, Manila

TAX IDENTIFICATION NO. :

HEIGHT :(ft & in)

Separated

BIRTH PLACE :

CITIZENSHIP :

RELIGION :

Filipino

A+

Roman Cath

FAMILY BACKGROUND
NAME

AGE

OCCUPATION / PROFESSION

67

Ar chitect (retired)

61

Housewife

Rhia Liza Mortera- Jabonillo

37

Medical Technologist

Ann Dominique Mortera

18

Student

SPOUSE (If Married)

N/A

N/A

CHILDREN

N/A

N/A

FATHER

- Mortera II, Florentino Quiobo

MOTHER -Mortera, Cornelia Mota

NAME OF BU
GOVERNMENT

SIBLINGS

Eastern Sun

Ateneo

EDUCATION BACKGROUND
ELEMENTARY

HIGH SCHOOL

Name of School / University

Pilar College

Years Attende

School / University Location

R.T Lim Boulevard, Zamboanga City

Honors/ Award

Name of School / University

Don Pablo Lorenzo Memorial High School

Years Attende

School / University Location

Governor Ramos, Santa Maria, Zamboanga City

Honors/ Award

Name of School / Universit

COLLEGE DEGREE

Course Taken

Brent Hpspital and Colleges Incorporated

B.S. Nursing

Location

R.T. Lim Boulevard

Years Attended

2003-2007 (4 years)

If not complet
finished:

Name of School / University

POST GRADUATE
DEGREE

Course Taken

Medina College

Masters in Nursing

PROFESSIONAL LICENSURE EXAM TAKEN:

DATE TAKEN:

Philippine Nursing Licensure Exam

Location

Ozamis city

Years Attended

2013-present

GOVERNMENT EXAMINATION TAKEN :

June 10 & 11 2007

LANGAUGE(S) / DIALECT SPOKEN :

If not complet
finished:

N/A

HOBBIES / SPORTS / INTERESTS :

Tagalog, bisaya, chavacano, tausug & Ilongo

OFFICE EQUIPMENT YOU CAN OPERATE :

OTHER SKILLS

verbal and
analytical,
skills,etc.

Playing Basketball, Reading, Watching movies

MEDICAL EQUIPMENT YOU CAN OPERATE :

computers, printers,
copiers, etc.

suction pump, nebulizer, pulse

oximeter

EMPLOYMENT BACKGROUND
POSITION

NAME OF COMPANY

(Start with the most recent)

LOCATION

Volunteer EMT

Philippine Red Cross

Petit Barracks, Zamboanga C

Staff Nurse

Eastern Sun Medical and Diagnostic Center

Siocon, Zamboanga del Nor

Safety Officer

Bigfish Foods Corporation

Clinical Instructor

Brent Hospital and Colleges Incorporated

Staff Nurse

Al- Mansoori MedicalCenter

Recodo Zamboanga City

R.T. Lim Boulevard , Zamboang

abu-dhabi

HEALTH STATUS
1. Are you able to perform privileges requested without harm or injury to patients or client?
2. Have you been hospitalized any time during the past five (5) years?
3. Have you been diagnosed to have minor/major illness/es during childhood or previous years?
4. Do you have any limitations on your health, life disability insurance, or have you ever been denied or rated under such coverage?
5. Have you ever had any problems with alcohol or drug dependency?
6. Have you ever participated in the Physician Recovery Chanel?
7. Have undergone or currently undergoing any medication that may affect either your motor skills or judgment (e.g. affect clinical judgment)?
8. Do you have any limitations in carrying out any activity or work load?
9. Do you have any form of body tattoo or piercing?
10. Rate your present overall Health Status :

Yes

No

Fair Poor

If answer is Yes, please identify which part of the body: _________________

If answer is Poor, why? _______________________________________________________

* Should your answer to any of the above health questions is YES, please provide details on a separate sheet.

PROFESSIONAL DATA (For Licensed Professionals)

Are you board eligible ?
PRC LICENSE NO. :

PROFESSIONAL
AFFILIATIONS

Yes No
457821

Are you board certified ? Yes No

EXPIRATION DATE: 05/24/2017

Has your board certification ever been voluntarily re

IVT LICENSE NO. (For Nurses )

06-023698

NAME OF ORGANIZATION

INCLUSIVE DATES

Philippine Red Cross

September 8, 2015- present

Philippine Nurses Association

PROFESSIONAL
AFFILIATIONS

2008- 2013

1. Are there any disciplinary actions initiated and/or now pending against you by any licensure board ?
2. Has your license to practice your profession in any state ever been denied, limited, suspended, revoked, placed on probation or voluntarily
relinquished?

3. Have you ever been suspended, sanctioned or otherwise restricted from participating in any private or government program (e.g. health insura

4. Have you ever been the subject of investigation by any private or government agancy concerning your participation in any private or governm
program (e.g. health insurance)?
5. Has your PRC license ever been limited, suspended revoked or voluntarily relinquished ?
6. Have you ever been convicted of felony or misdemeanor other than minor traffic violations?
* Should your answer to any of the above questions is YES, please provide details on a separate sheet.

OTHER INFORMATION

1. Do you have any relative/s employed withWest Metro Medical Center or any company of Metro Pacific Investment Corp (MPIC).? Yes No I
Company ? (Please specify Name, Position & Department) _________________________________________________________________________

2. Have you been dismissed or suspended from the service of any employer ? Yes No If yes, why? ________________________________________

3. Has any case been filed against you in any civil court in or outside the country? Yes No If yes, what's the status ? Dismissed Pen
* Should your answer to any of the above questions is YES, please provide details on a separate sheet.

REFERENCES

LIST AT LEAST THREE (3) PROFESSIONAL REFERENCES WHO HAVE PERSONAL KNOWLEDGE AND CAN EVALUATE YOUR PERFORMANCE NOT INCLUDING CURRENT PART
RELATIVES. PROVIDE COMPLETE ADDRESS AND CONTACT INFORMATION.

NAME

COMPANY / ADDRESS

Dr.Juliet Saracho, M.D.

Eastern Sun Medical and Diagnostic Center, Siocon, ZDN

Helen Lim (Senior Medical Technologist)

Zamboanga City Medical Center

Jayson R. Natividad, R.N., M.N.

Brent Hospital and Colleges Incorporated

ON THE BOX PROVIDED BELOW, PLEASE DRAW A MAP OR SKETCH SHOWING HOW TO GET TO YOUR HOUSE FROM THE NEAREST TOWN OR VILLAGE. PLEASE
LANDMARKS, E.G. SCHOOL, MALL, CHURCH, ETC.

www.google
.com.ph/ma
ps/place/Mo
neyGram++RD+Pawns
hop,
+San+Jose
+Main+Roa
d/@6.92039
38,122.048
3759,19.5z/
data=!4m2!
3m1!
1s0x325041
e6fa37ac9f:
0xa3685ced
12d6463a

1s0x325041
e6fa37ac9f:
0xa3685ced
12d6463a

PLEASE ANSWER BRIEFLY THE QUESTIONS BELOW:

Why do you want to join West Metro Medical Center? I Believe that with this profession, I can make a difference, and make people feel better.

i believe that in this intitution I can further enhance my skills, grow personally and professionally and I will be able to immerse my self with u
futher improve and develp my nursing and leadership potentials to serve the community of Zamboanga .

What are your strengths? Weaknesses? I have outstanding leadership qualities and interpersonal skills, which help me to coordinate well with my
I do not quit easily, until the work is done in a proper manner; its my major weaknes

What has been your greatest achievement?

I have 2 achievements which I consider made the most impact in my life and career; First is passing the board exam. It opened doors for me
and made me become a more responsible and productive citizen. Second is when I was employed as Clinical Instructor. the opportunity t
students and seeing them develop into professionals is very satisfying.

DECLARATION

I hereby affirm to the best of my knowledge that all my answers to the foregoing are true and correct. I authorize the company representative
statements and details contained in this Application. I futher authorize background check to be conducted in areas that cover character and gene

I ackowledge that filing of this application form does not entitle me to any acquired right and Cardinal Santos Medical Center may dispose my
understand that any false or misleading information in this application and/or interview which may be subsequently found shall cause for my dism

Signature :
Applicants' Printed N
Date Accomplished :

Bryan Florentino M

T APPLICATION FORM
EXPECTED SALARY :

10,000

NICKNAME :

Bry

bryan.mortera@yahoo.com
Place of Marriage : N/A
GENDER :

Male

Female

PAG-IBIG NO. :
RELIGION :

Roman Catholic

NAME OF BUSINESS/ COMPANY/INSTITUTION/

GOVERNMENT AGENCY / SCHOOL (If still studying)

Eastern Sun Medical and Diagnostic Center

Ateneo de Zamboanga University
N/A
N/A

Years Attended

1991-1997 (6 years)

Honors/ Awards upon graduation

Years Attended

Loyalty award
2000-2001 (1 year)

Honors/ Awards upon graduation

N/A

If not completed, uo tp what level or no. of units

finished:

If not completed, uo tp what level or no. of units

finished:
36 units
DATE TAKEN:

N/A
OTHER SKILLS :
verbal and written communication, leadership,
analytical, planning and organizing , computing
skills,etc.

AED, INFUSION PUMPS, CARDIAC

MONITOR, ETC.

LOCATION

INCLUSIVE MONTH &

YEARS

Petit Barracks, Zamboanga City

5 months

Siocon, Zamboanga del Norte

1 year and 7 months

Recodo Zamboanga City

5 months

R.T. Lim Boulevard , Zamboanga City

2years and 5 months

abu-dhabi

1 year

s or client?

Yes

No

Yes

No

No

previous years?

Yes

ou ever been denied or rated under such coverage?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

r your motor skills or judgment (e.g. affect clinical judgment)?

r is Yes, please identify which part of the body: _______________________________________

oor, why? ______________________________________________________________________

a separate sheet.

Has your board certification ever been voluntarily relinquished ?

Yes

EXPIRATION DATE : 05/24/15

RENEWED
POSITION HELD
RCERT Member

No

member

any licensure board ?

Yes

ited, suspended, revoked, placed on probation or voluntarily

No

Yes

No

Yes

No

Yes

No

nquished ?

Yes

No

ffic violations?

Yes

No

ipating in any private or government program (e.g. health insurance)?

agancy concerning your participation in any private or government

ate sheet.

ompany of Metro Pacific Investment Corp (MPIC).? Yes No If yes, who & what MPIC
___________________________________________________
Yes No If yes, why? ____________________________________________

? Yes No If yes, what's the status ? Dismissed Pending On-going

ate sheet.

AND CAN EVALUATE YOUR PERFORMANCE NOT INCLUDING CURRENT PARTNERS, ASSOCIATES IN PRACTICE OR

CONTACT NUMBER/S

9361882128
993-0146
9975090810

GET TO YOUR HOUSE FROM THE NEAREST TOWN OR VILLAGE. PLEASE SHOW THE NEAREST PROMINENT

ession, I can make a difference, and make people feel better.

ly and professionally and I will be able to immerse my self with unfamiliar situations to

dership potentials to serve the community of Zamboanga .

nd interpersonal skills, which help me to coordinate well with my colleagues.

knes

d career; First is passing the board exam. It opened doors for me to practice my profession
is when I was employed as Clinical Instructor. the opportunity to to impart knowledge to
develop into professionals is very satisfying.

ng are true and correct. I authorize the company representative to conduct investigation of all
nd check to be conducted in areas that cover character and general reputation.

uired right and Cardinal Santos Medical Center may dispose my application if so desires. I fully
erview which may be subsequently found shall cause for my dismissal.

Bryan Florentino Mota Mortera IV

2/24/2016