DOLE-SENA FORM No.

1
(Request for Assistance Form)

Republic of the Philippines

Department of Labor and Employment
NATIONAL CAPITAL REGION
CAMANAVA FIELD OFFICE

Date Filed:

SINGLE-ENTRY APPROACH (SENA)

(Per Department Order No. 107, Series of 2010)
Reference No.:

SEAD-NCR-CFO-________________

Name of Requesting Party:

(Pangalan)

Name of Responding Party:

(Pangalan)

_________________________________________________
Pls check ()
Male
Female
Union
Company

_______________________________________________________________
Pls. check ()

Male

Female

Union Company
Nature of Business
(Negosyo):_______________________________________
_______________________________________________________________

Address:
(Tirahan)__________________________________________
_________________________________________________

Total No. of Employee:

Male

Female

Tel. /Cel./Fax/E-mail:________________________________
_________________________________________________
Date of Employment:_______________________________

Contact Person:__________________________________________________
(Taong Kakausapin sa Kumpanya)

(Kailan nakapasok sa trabaho)

Position:________________________________________________________
Years of Service:___________________________________
(Taon sa Serbisyo)

Address:________________________________________________________

Nature of Work:
(Trabaho):_______________________________________
CLAIM/ISSUES
(Please check the appropriate
box/es)

(Katungkulan)

_______________________________________________________________
Tel. /Cel./Fax/E-mail:______________________________________________

RELIEF PRAYED FOR

(Ano ang gusto niyong solusyon

ACTION TAKEN
(To be filled-out by SENA Desk Officer)

sa reklamo o problema?)
Advise and Counseling
Illegal Dismissal
Illegal Dismissal with Money
Claims

Payment of Money Claims

Money Claims
Non-Payment/Underpayment
of:

Cessation of ULP acts

1.

wage

2.
Overtime Pay
3.
Night-Shift
Differential Pay
4.
Service incentive
leave

Reinstatement

Restitution/Correction of
violations of Occupational
Safety
and Health Standards
Audit/Examination of
Union Funds
Others (Please Specify)

Set for joint Conference on

___________________________________
Settlement agreement signed
on________________________________
Withdrawal by either or both
parties
Referred to _________________________
BY REASON OF:

5.

Holiday Pay

6.

SSS

reach an agreement within

7.

Philhealth

the 30-day mandatory

8.

PAG-IBIG

conciliation-mediation period;

Unfair Labor Practice (ULP)

Inter/Intra Union Dispute
Non-compliance with
Occupational
Health and Safety Standards
Reduction of Workforce
Others (Please Specify

Failure of the parties to

Failure of the requesting

party to appear in two (2)
scheduled consecutive
conferences despite due
notice.
Pre-Termination of the
proceedings with request of
issuance of Referral Form
_______________________________
REMARKS:___________________________

___________________________

_______________________________

______________________

Requesting Party's Signature

(Signature Over Printed Name)

SENA Desk Officer

(Signature Over Printed Name)

DOLE SENA Form 02-2010 / Notice

Republic of the Philippines

Department of Labor and Employment
NATIONAL CAPITAL REGION
CAMANAVA FIELD OFFICE

SINGLE ENTRY APPROACH (SENA)

(Per Department Order No. 107, Series of 2010, dated 5 October 2010)

IN THE MATTER OF THE REQUEST

FOR CONCILIATION FILED BY:
_______________________
_______________________

Requesting Party

SEAD-NCR-CFO-________________

_________________________
_________________________
Respondent

NOTICE OF CONFERENCE
________________________
__________________________
__________________________

G R E E T I N G S:
In connection with the above-entitled request, you are invited to a conciliation
conference before
_______________, on ____________ at _________, this office, __________________________________
_____________________________________________________.
Your presence and cooperation is necessary for purposes of resolving the issues
within thirty (30) days from filing of the request per Department Order No. 107, Series of
2010.
Lawyer may be allowed to join the conference only to render advice to clients.
Lawyer, agents or attorneys may appear in behalf of any of the parties provided they
could show a special power of attorney granting them authority to represent and enter into a
binding agreement for their principal. (Section 3 of D.O. No. 107 Series of 2010.
Caloocan City, Philippines, _____________.

BY AUTHORITY OF THE REGIONAL

DIRECTOR:
___________________________________
Desk Officer

DOLE SENA Form 03-2010

Republic of the Philippines

Department of Labor and Employment
NATIONAL CAPITAL REGION
CAMANAVA FIELD OFFICE
SINGLE ENTRY APPROACH (SENA)
(Per Department Order No. 107, Series of 2010, dated 5 October 2010)

APPEARANCE
Requesting Party

1.
2.
3.
4.
5.

_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________

Responding Party

1. _____________________________________
2. _____________________________________
3. _____________________________________
4. _____________________________________
5. _____________________________________

MINUTES OF CONFERENCE
COMPANY: _______________________________________
_____________________________
TIME: _________________

SEAD-NCR-CFO-

DATE: _______________________________

_______________________________________________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

__________________________
Requesting Party
(Printed Name over Signature)
over Signature)

__________________________
Responding Party
(Printed Name

Jocelyn H. Ancheta
SENA Desk Office
DOLE SENA Form 04-2010 / Agreement

Republic of the Philippines

Department of Labor and Employment
NATIONAL CAPITAL REGION
CAMANAVA FIELD OFFICE
SINGLE ENTRY APPROACH (SENA)
(Per Department Order No. 107, Series of 2010, dated 5 October 2010)

IN THE MATTER OF THE REQUEST

FOR CONCILIATION FILED BY:

Requesting Party/ies
SEAD-NCR-CFO____________________
Respondent

SETTLEMENT AGREEMENT
In connection with the above-entitled request, the parties fully
understand and voluntarily agreed on the following:

The
foregoing
terms
of
agreement
represent
the
complete/partial settlement of the issue/s that is/are the subject of
the conciliation conference /s. Both parties agree to ensure voluntary
and faithful compliance with the above terms of agreement and shall
submit a report of compliance to this Office on the date mentioned
above and which parties agreed in this case of partial settlement.
In case of non-compliance, the parties agree that the
settlement agreement shall be enforced by the sheriff of the DOLE
Regional Office or NLRC, in accordance with existing rules and
procedures on execution of orders and resolutions.
IN WITNESS WHEREOF, the parties hereunto affixed their
signatures this ______th day of ________________ at Caloocan City,
Philippines.

________________________
Requesting Party

(Signature over printed name)

Assisted by:
_______________________
CABANSAG

SENA Desk Officer

her authorized
(Signature over Printed Name)
Printed Name)

DOLE SENA Form 06-2010 / Referral

____________________
For Responding Party

Approved:
ANDREA P.
Head of Office or
(Signature over

Republic of the Philippines

Department of Labor and Employment
NATIONAL CAPITAL REGION
CAMANAVA FIELD OFFICE
SINGLE ENTRY APPROACH (SENA)
(Per Department Order No. 107, Series of 2010, dated 5 October 2010)

IN THE MATTER OF THE REQUEST

FOR CONCILIATION FILED BY:
____________________________________
Requesting Party
SEAD-NCR-CFO_________________
____________________________________
Respondent

REFERRAL
FOR:
The requesting party/parties submitted his/her/their grievance through
request for assistance/preventive conciliation-mediation of this Office. There
has/have
been
_______
(___)
conference/s
conducted
from
__________________________. However, the request for assistance/preventive
conciliation-mediation proceedings did not prosper because of:
A. Non-Appearance
(
) The failure of the requesting party to appear.
(
) The failure of the responding party to appear.
(
) The failure of the both parties to appear.
B. Non-submission to the conciliation-mediation process
(
) The requesting party declined to submit to conciliation-mediation
process.
(
) The responding party declined to submit conciliation-mediation
process.
(
) Both parties declined to submit conciliation-mediation process.
C. Failure to reach a settlement
(
) Parties failed to reach an agreement
D. Others (please specify)
In connection with the above-entitled request, may we refer to your Office
for appropriate action, the herein SENA request which was initially handled by
SENA Desk Officer _______________, on ______________________, pursuant to DOLE
Department Order No. 107, Series of 2011.

_______________________
SENA Desk

Officer

(Signature over Printed

Name)

Noted:
_____________________________
Head of Office or His/Her Authorized
Representative
(Signature over Printed Name)

DOLE SENA Form No. 5

Quitclaim & Release

Republic of the Philippines

Date Filed:
Department of Labor and Employment
National Capital Region
CAMANAVA Field Office
SINGLE ENTRY APPROACH (SENA)
(Per Department Order No. 107, Series of 2010, dated 5 October 2010)

IN THE MATTER OF REQUEST FOR ASSISTANCE OF:

___________________________________
Requesting Party/ies
SEAD-NCR-CFO- ____________
___________________________________
Responding Party/ies/Employer

QUITCLAIM AND RELEASE

(PAGTALIKOD AT PAGPAPAWALANG SAYSAY)
I, __________________________________, of legal age and residing at ______________________________________.
(AKO si, __________________________, nasa hustong gulang at nakatira sa __________________________________.)
for and in consideration of the total amount of ___________________________________________________ (P____________)
(bilang konsiderasyon sa kabuuang halaga (P_______________________________________)
do hereby release and discharge ________________________________________________________
the foresaid companies/corporations/person and its officer/s, person/s from any money claims by way of underpaid wages,separation
pay/retirement pay, overtime pay or otherwise, as may due to me in connection with my past employment with the aforementioned
company/corporation/person, its officers/persons.
(ay aking/aming pinawawalang saysay at tinatalikdan ang/si __________________________________________
ang nabanggit na kumpanya/korporasyon/tao at ang mga tauhan nito mula sa anumang paghahabol ng nauukol sa pananalapi
sa pamamagitan ng di nababayarang sahod o anupaman na karapat-dapat para sa akin na may kaugnayan sa aking pagtatrabaho sa
kumpanya o korporasyon o sa mga opisyales o tauhan nito)
I am executing this Quitclaim and Release, freely and voluntary before this Office without any force or duress
(Isinisigaw ko ang Pagtalikod at Pagpapawalang-saysay na ito na may kalayaan at kusang loob sa harapan ng
tanggapang ito ng walang pamimilit o pamumuwersa)
and as part of the settlement agreement reached during the conciliating-mediation process conducted in the
DOLE-NCR-CAMANAVA FIELD OFFICE.
(at bilang bahagi ng napagkasunduan buhat sa proseso ng conciliation-mediation dito sa DOLE-NCR-CAMANAVA FO)
IN VIEW WHEREOF, WE hereto set my hand this _________ day of ________, 2014 in Camanava Field Office Caloocan City.
(DAHIL DITO, Kami ay lumagda ngayong araw ng __________________ sa DOLE-CAMANAVA Field Office, Caloocan City).

________________________
Signature of Requesting Party/ies
(Lagda ng Partidong Humiling)
Signed in the Presence of (Nilagdaan sa Harapan ni):
________________________
Signature over Printed Name
(Pangalan at Lagda)
__________________
Posisyon/Katungkulan
WITNESSED this _______ day of _______________ in Caloocan City, Philippines.
____________________________
SENA Desk Officer
(Signature over Printed Name)
NOTED:
ANDREA P. CABANSAG
Director II, DOLE-NCR-CAMANAVA Field Office
(Signature over Printed Name)