Republic of the Philippines

Province of Iloilo
Municipality of Santa Barbara

APPLICATION FORM FOR BHW REGISTRATION

THE HONORABLE MAYOR

Chairperson, Local Health Board
Municipality of Santa Barbara, Iloilo

Attention: The Chairperson

BHW Registration and Accreditation Committee

Sir/madam:

In line with the implementation of RA 7883 otherwise known as “The Barangay Health
Workers` Benefits and Incentive Act of 1995”, the undersigned who is presently serving as a
community volunteer health worker at Barangay Zone II - Poblacion, Santa Barbara, Iloilo.

Is submitting this accomplished application form and required attachment for the
processing of my application for Registration as a Barangay Health Worker of the Municipality
of Santa Barbara, Province of Iloilo.

Enclosed are the following:

( ) Accomplished BHW Registration Accreditation Form Ib

( ) Birth Certification
( ) Certificate of completion of the BHW Basic Training Course
( ) Certificate of one year voluntary health service from the rural Health Midwife or
From duly authorized NGO and the head of the BHW Association/Federation
( ) Medical Certificate from a government physician
( ) Barangay Certificate of Residence

REGINE MARIE S. OMILIG

Barangay Health Worker

BHW Registration & Accreditation Form Ia

 Republic of the Philippines
Province of Iloilo
Municipality of Santa Barbara
Local Health Board

CERTIFICATION OF REGISTRATION
BHW Registration No. ILO – 15 – 00394

Is hereby award to

CRISTITA S. LEBUNA
As registered Barangay Health Worker (BHW) pursuant to the provision of Republic
Act No. 7883 dated February 20, 1995 and in compliance
with Implementing Rules and Regulations of the Act dated May 21, 1996.

The said person shall be included in the official

registry list of BHWs in the country.

This registration is effective for a period of from

January 1, 2024 to December 31, 2024 after which he/she shall apply for a renewal.

Given at Santa Barbara, Iloilo this 5th day of January in the year of our Lord Two Thousand
Twenty-four.

In testimony hereof, the seal of the city/municipality government of Santa Barbara and
the signatures of Mayor/Chairperson of the Local Health Board and the Chairperson of the BHW
Registration and Accreditation Committee are hereby affixed.

ZOE N. SUCALDITO JR., M.D.

Chairperson
BHW Registration & Accreditation Committee

HON. DENNIS S. SUPERFICIAL, M.D

Municipal Mayor
Chairperson, Local Health Board
 Republic of the Philippines
Province of Iloilo
Municipality of Santa Barbara
Local Health Board

APPLICATION FORM FOR BHW RENEWAL OF REGISTRATION

THE HONORABLE MAYOR

Chairperson, Local Health Board
Municipality of Santa Barbara, Iloilo

Attention: The Chairperson

BHW Registration and Accreditation Committee

Sir/Madam:

In line with the Implementation of RA 7883 otherwise known as “The Barangay Health
Workers` Benefits and Incentives Act 1995”, the undersigned with Registration No. ILO – 21 -
00519 issued on 01 – 20 – 21 is submitting this accomplished application form and required
attachments for the renewal of my Registration as a Barangay Health Worker of the
city/municipality.

Accomplished application form and required attachments for the renewal of Registration
as a Barangay Health Worker of the city/Municipality.

Enclosed are the following:

( ) Certificate of Registration
( ) Updated BHW Registration Accreditation Form Ib
( ) Certificate of Services rendered for the year prior to the renewal of registration by
The RHM or NGO representative and the head of BHW Association.

REGINE MARIE S. OMILIG

Barangay Health Worker
 Republic of the Philippines
Province of Iloilo
Municipality of Santa Barbara

APPLICATION FORM FOR BHW ACCREDITATION

THE HONORABLE MAYOR

Chairperson, Local Health Board
Municipality of Santa Barbara, Iloilo

Attention: The Chairperson

BHW Registration and Accreditation Committee
Sir / Madam:

In line with the Implementation of Republic Act No. 7883 otherwise known as “The
Barangay Health Workers` Benefits and Incentives Act 1995”, the undersigned with who is
presently serving as a community volunteer health worker at Barangay Zone II - Poblacion,
Santa Barbara, Iloilo and with Registration No. ILO – 21 – 00519 issued on January 20,
2021 is submitting accomplished application form and required attachments for the processing of
my application for Accreditation as a Barangay Health Worker of the city/Municipality

Enclosed are the following:

( ) Certificate of Registration
( ) Three year Accomplishment Report certified by an RHU or duly authorized
Representative of an NGO and the head of BHW Association/ Federation

REGINE MARIE S. OMILIG

Barangay Health Worker

BHW Registration & Accreditation Form 2

 Republic of the Philippines
Province of Iloilo
Municipality of Santa Barbara

THE LOCAL HEALTH BOARD OF SANTA BARBARA

Present this

CERTIFICATE OF ACCREDITATION
to

CRISTITA S. LEBUNA
With Accreditation No. ILO – 15 – 09 – 00394 in recognition of her voluntary
involvement in community development as well in the delivery of Primary Health
Care services and development of the nation.

Given this 15th day of March, 2024.

HON. CHARLES LOUIGI BADON, MD, MPM ZOE N. SUCALDITO JR., M.D.
Chairperson, SB Committee on Health Municipal Health Officer

HON. DENNIS S. SUPERFICIAL, M.D.

Municipal Mayor
 Republic of the Philippines
Province of Iloilo
Municipality of Santa Barbara
Barangay Zone II - Poblacion

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CERTIFICATION
To Whom It May Concern:

This is to certify that REGINE MARIE S. OMILIG, 24 years old, Female, a

resident of Rodriguez St., Barangay Zone II - Poblacion, Sta. Barbara, Iloilo., undergo
One year (1) voluntary health service rendered as Barangay Health Worker in Barangay
Zone II - Poblacion, Sta. Barbara, Iloilo. on January 05, 2019 to January 05, 2020.

This certification is issued upon the request of the above-mentioned person for
whatever purpose/s it may serve her/ him best.

Issued on this 13th day of March, 2024 at Barangay Zone II Poblacion, Santa Barbara,
Iloilo.

Certified by:

ALONA F. PEÑOL, RM.

Midwife Supervisor

Noted by:

ZOE N. SUCALDITO JR., M.D.

Municipal Health Officer
 Republic of the Philippines
Province of Iloilo
Municipality of Santa Barbara

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MUNICIPAL HEALTH OFFICE

MEDICAL CERTIFICATE

____________________

To Whom It May Concern:

This is to certify that GLORIAN T. CORNAL, 29 years old, Married, a

resident of Barangay Zone II - Poblacion, Sta. Barbara, Iloilo, underwent a
physical examination at this facility and was found to be physically fit.

This certification is issued for whatever purpose it may serve.

ZOE N. SUCALDITO JR., M.D.

Municipal Health Officer
Tel. No. 033-503-9042
Santa Barbara RHU
Lic. # 0117881
 Requirement BHW
White folder (long)

1. BHW Registration Form (Bio-Data)

2. Certificate of Residency
3. Certification of 1 year Volunteer BHW
4. Medical Certificate from a government physician.
5. Birth Certificate (Photocopy)
6. BHW Basic Training Course (Photocopy)
7. Training Certification (Photocopy)
8. Application form for BHW Registration (5pcs)
9. Application form for BHW RENEWAL of Registration (4pcs)
10. Certificate of Registration
11. Application form for BHW Accreditation
12. Certificate of Accredited