Guidelines on the Conduct of the Basic Course in Occupational Medicine

Version: 1.01 Approved by: National Board, 2018-2019

Last Amendment: 21 July 2018 Date Approved: 05 September 2018
Contact Officer: Chair, BCOM Subcommittee Next Review: April 2019

DOLE-OSHC Prescribed Course on Basic Occupational Medicine for Physicians and Dentists
Quezon City
Host: PCOM ____________CHAPTER
Date: ________________
June 22 - 29, 2019
Venue: Occupational
___________________________
Safety and Health Center,
North Avenue cor. Agham Road, Diliman, Quezon City

REGISTRATION FORM

Pls. check applicable category: Physician Dentist

Name: (Please
write legibly)
Last Name First Name Suffix Middle Name
Contact Details
Email Mobile
Address: No.

Residence or Phone
No.
Clinic Address:
Professional Details
Designation: PRC No.

Specialty:

Registration fee: Amount: Php 14,000.00

O.R. No. Date of Payment
Please put a check (ü) mark on the terms of this registration that you agree on.

o I agree to give the details above to PCOM, Inc. for the purpose of complying with the needed data for
submission to the Department of Labor and Employment, the Professional Regulation Commission,
Philippine Medical Association and Philippine Academy of Family Physicians.
o I agree and understand that this registration form shall be securely disposed of based on the schedule
written in the latest version of the PCOM Data Privacy Manual.

Signature

Annex 11.7
Attendance Sheet

ATTENDANCE SHEET: PCOM

PHILIPPINE COLLEGE OF OCCUPATIONAL MEDICINE, INC.
Basic Course in Occupational Medicine

Version 1.01 Approved: Board Resolution # 2018-07-0090 Page 40 of 65